FORM-2 Applicant ID: 2223563

Penslon Number: MH/BAN/48475/

UNEXEMPTED/EXEMPTED ESTABLISHMENTS
NOMINATIONAND DECLARATION FORM FOR
DeGlaration and Nomination Form under the Emplovees Provident Fund and Employees Pension Scheme (Rule 25 of
Penonsultancy Services Employees Provident Fund Rules &Paragraph &
Paragraph 18 of the Employees
Pension Scheme, 1995)
1. Name(In Block Letters): SANJIBAN DEY
2. Father's /Husband's Name: Kartick Dey
3. Date of Birth: 08/01/2000
4. Male/Female: Male
5. Marital Status:Single
6. PF ACCount Number: MH/BANJ48475/
7. Address:

Permanent : Circular Road, Milanpally Mukunda Das Road Gopal Pan Ghar Siliguri West Bengal 734005
Temporary : 1/886, Aloywin Traders, Anna Salai. Rice Mill Road. Vedachalam Nagar Quaithe Millath Street
Opposite Jk Builders Chennai Tamil Nadu 600100
8. (a)Date of joiningEPF Scheme,1952: 2104/2025
(b)Date of joining E.P.Scheme, 1995 : 21/04/2025

PART -A(EPF)
| hereby Nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned
below toreceive the amount standing to my credit in the Employees Provident Fund, in the event of my Death.
Name of the Address of the Nominee's Date of Birth Total Amount of If the Nominee is minor, name,
Nominee/ Nominees Relationship share of relationship and address of the
nominees with the accumulations in guardiarn who may receive the
member Provident Fund to beamount during the minority of
paid to each nominee. nominee
Saraswati Dey 1/886, Aloywin Mother 01-Jan-1982 100
Traders, Anna
Salai, Rice Mill
Road,
Vedachalam
Nagar, Quaithe
Millath Street,
Opposite Jk
Builders,
Chennaj
600100, Tamil
Nadu, India

n1certified thatlhave no family as defined in Para 2(g) of the Employees Provident Fund Scheme, 1952 and should |
acquire a family hereafter the above nomination should be deemed as cancelled.
M2 Certified that my father/ mother is /are dependent upon me.

Signature of the subscriber/member

05-Apr-2025 Page 1 of 2
 PART B (EPS)
(Para 18)
Relationship with the
Serial No Name of the Family Address of the Family member Date of Birth
member
member

Iacquire a
Certified that I have no family, as defined in Para 2 (vii) of Emplovees Pension Scheme, 1995 and should
family hereafter Ishall furnish particulars thereon in the above form.

Thereby nominate the following person for receiving the monthly widowpension (admissible under Para 16 (2Na) a
death without leaving any eligible family member Tor
(n) of the Employees Pension Scheme, 1995 in the event of my
receiving pension.
Relationship with the
Address of the nominee Date of Birth
Name of the nominee member

Mother
1/886, Aloywin Traders, Anna Salai, 01-Jan-1982
Ms. Saraswati Dey
Rice Mill Road, Vedachalam Nagar,
Quaithe Millath Street, Opposite Jk
Builders, Chennai- 600100, Tamil
Nadu, India

subscriber/member
Signature of the
Date: o7/4/20s
CERTIFICATE BY EMPLOYER
Smt./Kumari SANJIBAN DEY in
declaration and nomination has been signed before me by Shri/ him/her.
Certified thát the above him/her by me and got confirmed by
establishment after he/she has read the entries have been read over to
my

Signature of the employer or

05-Apr-2025 Page 2 of 2