NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/ EXEMPTED ESTABLISHMENTS. Declaration and Nomination Form under the Employees’ Provident Funds and Employees! Pension Scheme (Paragraphs 39 & Gt (1) of he Employees Provident Fund Scheme, 1952 and Paragraph 18 cl the Employees’ Pension scheme, 1995) 1. NomeinBeckicies) —: ANMOHAN MEHRA pee, (ate Sar DALAT RAM MeneA 3, Dateot Bith ayfoyhias A Sex >: MALE 5. Marta Status | UNMARRIED oon cea ctatr tad urrantnn 20H reomny 2-253, THAT, Got AURT DARD, UTTAM Ne, MEY Dent. PART — A (EPF) hereby nominate the persons) canes the nemination made by me peviusl ard nominal he parso(s) mentones bel” to receive the amount standing te my credit inthe Employees ProventFundin the event of my deat) = ‘saress ‘Nominees eation= Date of Total amcunt of share of the nominee is amino. ship wih he member Birth Accumulation in Prov fame &relafonenip & aderess Gert Fund tobe paid 0 ithe guaran who may ‘ech nominee | recaive the amount daring themnery ef naming a 4 5 = S5yes \oo7. 2{g) othe Employes! Provident Fund Scheme, 1952 and should jon shoul be deemed as cancelled. Signature or thumb impression of the subscriber FoonPart B (EPS) (Para 18) ‘herby fish bow pric of he members of my family who woud be eget eave wioweren persion tntherento my cet SNe, Nemeat tata Adsress Date of bith area 7 z i = 7 1 MANJEET KAUR — (/o— ES MoTHe; 2 PRAMAY HEWRA —(ro— QR yr BRoTHER 2 “ Cerfied thet have no family, 9 defined in para 2.) of Employes’ Pension Scheme, 1996 and shoul | acaure family ‘reste | shal furish particulars thereon inthe above form, | herby neminate he folowing person for recehng the manthy widow pension (admis uncer para 16 2a) a) In he evant of my deat witnat leaving any elgble family member for resting Pension. Name and Adsress ofthe Nowines Diao Bath Filationship wit the meribor 4 2 3 ‘Signatute or thumb impression of the subscriber CERTIFICATE BY EMPLOYER Signature of the employer or ther ‘Authoriod Officers of the Establishment Designation Name & Address ofthe Factory! Establishment or Rubber Stamp ThereonFORM {See sub-rule (1) of rule 6} Nomination 4,1, Shri/Shrimati/Kumar MAWMOHA A HEHRA_ whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shal be paid in proportion indicated against the name(s) ofthe nominee(s). 2.1 hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972. 3, Ihereby declare that | have no family within the meaning of clause (h) of section (2} of the said Act. 4, (a) My father/mother/parents is/are not dependent on me. (b) My husband's father/mother/parents is/are not dependent on my husband, 5, | have excluded my husband from my family by a notice dated to the Controlling Authority in terms of the proviso to clause (h) of section 2 of the said Act. 6. Nomination made herein invalidates my previous nomination, Nominee(s) SI ]NameoftheNominee | Address of the | Relationship | Age of | Proportion No Nominee with the | the | by which Employee | Nominee | the | gratuity will be shared z z 3 a 5 6 HAMMEET KAUR | R2IS3 Text THER | SSyAS | lool DTT4N WAR PB DER HE 10°54 | statement 41. Name of employee in ful 2. Sex. 3. Religion. 4, Whether unmarried/married/widow/widower, 5. Department/Branch/Section where employed. 7 6. Post held with Ticket or Seria No, if any. 7. Date of appointment. 8. Permanent address.{70 be retained by the imployer for fare EMPLOYEES’ PROVIDENT FUND ORGANISATION [Employeos Provident Funds Scheme, 1952 (Paragraph 34 & 57) & Employees’ Pension Schame, 1985 (Paragraph 24) (Ceciaration by a person taking up employment in any establishment on which EPF Scheme, 1952 ard Jor EPS, 1998 Is applicable) Name of the member | Fathers Nome Ki Spouse's Name] {Please ck whicheveris applicable) | MAWVMOHAN NERA {tate Sat DauaT Ram MeHRA DD/ MMIYYYY) a se Qi = 04-1994, —| TRemlerTransgender) | a egs9e Se Mg MALE ae Marital Status” (Wavied/Unalaied/ Widow Widower pe we i} perm mre & Emad AaeYE ABD BE YOMDMANU EP OMI CoM b)_Mobile Noe e = | ‘Whether earlier @ member of Employees’ Provident Fund Scheme, Yes/No ee ‘Whether earlier @ member of Employees’ Pension Scheme, 1995 Previous employment details: [if Yes to 7 AND/OR 8 above] 8) Universal Account Number: Yes Ne 1B) Previous BF Account Number: ©) _ Date of exit from previou @) Scheme Certificate No. (if issued) '@) Pension Payment Order (PPO) No. (if issued) hb us a ‘@) _ International Worker: Yes/No B)_yes, state country ef ongin (India Name of athe co ©) Passport No, : @)_Valcty of passport [(OD/MM/YYYY) te (ODIMIIYYYYN] 1 KYC Details: (attach self i 11 |) Bank Account No: & TFS Code ity) LApIA, 10 TeorerFOoosE FES NBolbIo00 [blovoytoooo bt b5 w Gi > ) AADHAR Number ____ | 5154 5)245958 ©) Permanent Account Number (PANY, avaliable DPEPM1b33N 4 : “UNDERTAKING 2} Certifies thatthe particulars are true tothe best of my knowledge. 2} Tauthorze EPFO to use my Aachar for vrifcation/authentication/eKYC purpose for service delivery. 5} Kindly transfer the funds and service details, sf applicable, orn the previous PF account as declared above tothe present PF. Account, (The transfer would be possible ony if the identified KY detail approved by previous employer has been verified by present employer Using his Digal Signature Cetfcate) '4) Incase of changes in above deta the same wil be intimates to employer atthe earest. wor ate: Pace: Signature of Member ‘and has been allotted PF Number r a 8 Inca he person was ears not a member of EPF Scheme, 1952 and EPS, 1995: © _(Past allotment of UAN) The UAN allotted for the member i... with Digital Signature Certificate ar Informe to fle physica! claim (FosEMPLOYEES! PROVIDENT FUND ORGANI (Declaration by a person taking up employment in any estab 1, | Name ofthe rember raat | MaAnnoHny Mean | Father's Name [A~ Spouse's Name 7] 1 in t | (Piease tick whichever is appicab (Please tick er is applicable) LATE SAL Davia T Pan Menen | ae " 3, | Date of Bi " { 3. [ Date or pith: (00 / mM 7 rrYY) A= O47 1975 (4 alee panera MALE [Ce | Mantl Status” (ariedtinr ried owl Widower OWvorce=) ; iy ene ee coed eae 2 | Unnapens [6 [@ Emanio:e Als ve RMD (50 YOM DMMNOIY O41 OF } wos tt tos ilo “Previous PF Recount hamiber Ryne @_ Dae af et rom previous employment: (OOIMINYTY) |e) Seheme Cerieate No. (issued) ——_ ee oe ; |] a) tntemational Worker tos to a > [a Passport No. @) Validity of passport [(OD/MM/YYYY) to (DD/MM/YYYY)} VCs) oro 0008L 6S (PU NBol\b1000 igeenteielt igen ee! 5\54 51M EISF DPFPM1b32N Unoeeranina 1) erie tha the partis are tue to thebestof my knomlcdoe 2} authorize EPFO to use my Aadnar for ver¥icaton/authentcalon/eKYG purpose for service delivery 3} Ky transfer te funds and servic etal, applicable, tom the previous PF account a dca eu ecsen erecpuran natn tree tet cet one Dereon ‘ 4, Incase of changes in above detats, the same wil be itates to employer at the earest iy” aa Vo? DECLARATION BY PRESENT EMPLOYER Rite mete reine rawr en ce ann 8. Incase the person was earlier not a member of EPF Scheine, 1952 and EPS, 1995; de eu eitaaete ny aalniiasel banat i penser tL a ai ee sit i eee becca 1 Have been uploaded and approved with OSC ge ae ere le Co a ora eee + Please Tick the Appropriate Option:~ c The RYC details of the above memter in the UAN database have buen approved wit) Da! Saratine © transfer request has been generated on portal + hse DSC of establghment are nc reistered with EPFO, the meiner has beer wore 10 Te Uy 113) for tranater of funds trom ts previous estab atment, ate ia aaa grate of Becher wet Saad ot 1 star,Nomination for unpaid dues in cash of death eerneas z 0.08 [Phone No aster Kave | MoTH ee — [P2283 UT 7aM dak pewpenr [sco] 992 6069194 Bank Details (Compulsory) bank Account No: itcode A ranch of Bank | Relationship A/C Holder Name Bank Name: Have you ever been involved in Criminal cases at any time or been involved for any offence if yes than give details: fue Have you ever been dismissed or discharged from services_ U0 __ Have you ever been involved in Indiscipline and insubordination if yes than give details (Vo ‘hereby declare that if the information (given by me) found false at any time/any stage during my tenure of ‘employment or during employment background verification, shall be liable for immediate dismissal from my service without any notice or compensations wh oe" \y? Signature of Applicant Left Thumb Impression " For Office Use Signature of Reporting Manager Signature of HR Department Name: Contact no- Remarks Date Place Page 20f2