FORM 2 (Revised) NOMINATION AND DECLARATION FORM (For Unenornpted / Exempted Establshmerts) Declaration and Nomination Form under the Employeos Provident Funds & Empioyeoe! Pension Scheme (Paragraph 33 and 61(1) ofthe Employees’ Provident Fund Scheme, 1952 8 Paragraph 18 ofthe Employees’ Pension Scheme, 1995) oe muploy.ce 2 Faners/ us ge Famers halen appesble +3. Date of Birth a DoB 4, Sex DAB 5, Martal Stas : Sasol /aastt ed. 2 Assaiathe, ed Tisinstd 7. Adress Permanent to be _wondioned Temporary | be mentioncel PART A (EPF) | hereby nominate the person (¢) / cancel the nomination made by me previously end nominate the person (s). ‘mentioned below receive the amount standing to my cred in the Employees’ Provident Fund, i the even! of my Death Telalamount | Wihenorineeis Nominees ffstareor | minor names tatorshp| 8° | accureiatens | relationship ad withthe | gin || inProvdent | sso the uerc- member A) Fundtobe | fanwhomay tooe- (wt) | aidteach | _wemeamount Ttonines’ | tring the minoriy| Name of the nominees Acdrose ‘fneines 4 2 3 4 5 5 [| Nemence HY ponsa coud Lf Henwins vo} | > - acidluest ee Bee Z pfetd [a ‘i “4 we" \ Norance 2 [fi] aun) Gams 4. *Centifed that! have no family 2s defined in par 2 (g) ofthe Employees’ Provetent Fund Scheme, 1952 and shout | ‘acquire a family hereafiar tha above nomination should be deamed ae carcele, 2. * Certfted that my father mother is/are cependent upon me. "Eee center at appioa isi anor resdion of the SubscriberPART B (EPS) (Para 18) | hereby fish betow particulars of the members of my family who Would De elaibieto receive widow chiéren pension the eventof my death a Ree and Antes of hs tai jspanitor ©) > Date pe Me Name Address, member 4 2 : iy pa | fet married adduct) ronenrt_| dl 2 Ae xh 3 Xu = ~ Cerlified that | have no family as defined inpsra 2 (vi) of Employees’ Pension Schome, 1996 and ‘hold l acquire aferily hereafter shall furnish partcutars thereon inthe above form. thereby nominafo the fellowing person, for rooelvingthe monthly widow persion [adnibsible under para 18 2(a) (8) n event of my death without leaving any elpibie famiy memerfor tecaiving pension, ‘Name & adress of the nominee DateotBirth | Relationship wth the member nes ike womences noms + actlices Leth fraotiaA li hee : if Dats; dueekeect dal Pr ee recall amen Signatur nur session ofihe subsoibat CERTIFIGATE BY EMPLOYER Certitied that the abave declaration and nomination has been signed | thumb impressed before me by ShriSrat Kum. mts employed in my establishment alter nelshe has read the entiies/eniris ive been tead over lohinvher by me and gol coafimed by hewihes, ‘Signatur ofthe employerorothor authorised Officers ofthe establishment: Piece ae Designation Dated. Nama and addrees of the Factory’ Estabishmantorrubber stamp thereof __ GUPTA