FORM 2 (Revised)
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLSIHMENTS
Declaration and Nomination Form under the Employees Provident Fund and Employees Pension Scheme.
(Paragraph 33 & 61(1) of the Employees Provident Fund Scheme, 1952 & Paragraph 18 of the Employees Pension Scheme, 1995)
FIRST NAME, MIDDLE NAME, LAST NAME
1. Name in CAPITALS:…………………………………………………………………………………………
FIRST NAME, MIDDLE NAME, LAST NAME
2. Fathers’ Name :……………………………………………………………………………………………….
DOB as per PAN record
3. Date of Birth: ……………………………………… Specify gender
4. Male/Female ……………………………………
Skip
Married/Unmarried/Divorcee/Widow 6. Account Number: MH/BAN/……………………
5. Marital Status: ………………………………………
Complete address details along with area pin code
7. Address : Permanent:…………………………………………………………………………………………..
……………………………………………………………………………………………
Complete address details along with area pin code
Temporary…………………………………………………………………………………………..
……………………………………………………………………………………………
PART – A ( EPF)
I hereby Nominate the person(s)/cancel the nomination made by me previously and nominate the person(s)
mentioned below to receive the amount standing to my credit in the Employees Provident Fund, in the event of
my Death.
Name of the Address of the Nominees Total Amount of If the Nominee is
Nominees Nominees Relationship with share of minor, name,
the member accumulations in relationship and
Provident Fund to address of the
be paid to each guardian who may
nominee. receive the amount
during the minority
of nominee
Provide Full name Complete address Specify relationship Share allocated to Guardian details
(First Name with area pin code with nominee respective nominee('s) (complete details
Middle Name
Last Name) Gross up shall be 100% along with address)
1. Certified that I have no family as defined in para 2(g) of the Employees Provident Fund Scheme, 1952
and should I acquire a family hereafter the above nomination should be deemed as cancelled.
2. Certified that my father/ mother is / are dependent upon me.
Tick option no. 2 if member is unmarried Signature of employee - Mandatory
Signature of the subscriber/member
P.T.O.
PART B (EPS) To be filled by employees who are "Unmarried"
(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children
Pension in the event of my death.
Serial Name Address of the family member Date of Birth Relationship with
Number of the family member the member
Parents Details - Complete address details along with DOB of nominee Specify
First name, Middle name Area pin code relationship with
last name nominee
Certified that I have no family, as defined in para 2 (vii) of Employees Pensin Scheme, 1995 and should I acquire
a family hereafter I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16
(2)(a)(i) and (ii) in the event of my death without leaving any eligible family member for receiving pension.
Name and address of the nominee Date of Birth Relationship with the member
To be filled by employee who are "Married"
Provide the details of Spouse DOB of spouse Provide relationship (Husband/Wife)
Date: Please provide the detail Signature by member - Mandatory
Signature of the member/subscriber
CERTIFICATE BY EMPLOYER To be filled by employer
Certified that the above declaration and nomination has been signed/ thumb impressed before me by Shri/
Smt./Kumari ……………………… employed in my establishment after he/she has read the entries have been
read over to him/her by me and got confirmed by him/her.
Date
Signature of the employer or
Other authorized Officer of the establishment
Name and Address of the Factory/Establishment
