(FORM 2 REVISED)
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)
1. Name (IN BLOCK LETTERS) : Pradeep Vidhya Sagar Nautiyal
Name Father’s / Husband’s Name Surname
2. Date of Birth : 19-04-1992 3. Account No. - 355199081596
4. *Sex : MALE/FEMALE: MALE 5. Marital Status - Married
6. Address Permanent / Temporary : L2/73, Second floor, front side, Mohan Garden, Uttam Nagar, New Delhi-110059
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.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee
1 2 3 4 5 6
Praveen L2/73, Second floor, Brother 19-04-1992 100%
front side, Mohan
Garden, Uttam
Nagar, New Delhi-
110059
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.
Strike out whichever is not applicable Signature/or thumb impression
of the subscriber
PART – (EPS)
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 premature death in service.
Sr. No Name & Address of the Family Member Age Relationship with the member
(1) (2) (3) (4)
1 Megha Sati 27 Wife
Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.
Name and Address of Date of Birth Relationship with member
the nominee
Megha Sati 03-07-1996 Wife
Date 29-07-2024
Signature or thumb impression
of the subscriber
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./ Miss
PRADEEP NAUTIYAL employed in my establishment after he/she has read the entries / the entries have been read over to him/her by
me and got confirmed by him/her.
Date : Signature of the employer or other authorised officer of the
establishment
Place :
Name & address of the Factory /Establishment
Date :
