pate of Appointrnent :

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"
(P. F. Deduction date) : ( FORM 2 (REVISED) J

NOMINATION & DECLARATION FORM Group No.

FOR UNEXEMPTED I EXEMPTED ESTABLISHMENTS
Office:

Declaration and Nomination Form under the Employee's Provident Funds

and Employees' Pension Scheme

(Paragraph 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 andPara
18 of the Employees' Pension Scheme, 1995)

2 FATHER'S I HUSBAND'S NAME' _

3 DATE OF BIRTH: 4. SEX: _

(Male I Female)
5. •.MARITAL STATUS:
(Married / Unmarried I Widow I Widower)

6. ACCOUNT NO. : _

7. ADDRESS:

PART-A (EPF)

I hereby nominate the person(s) I 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 th-e event of my death.

'.
- . Norninee's
Total arr.t
or share of accumulationin
If lhe nominee is
minor. name &
relationship & add.
Name & Address of the Nominee(s) relationship with Dale of of the guardian who
Birth PF to be
the member paid to each may receive the I
nominee amount during
minoritv of nominee
(1 )
I
(2) (3) (4) (5)

.~,

",
;.

1. • Certified that I have no family as defined in para 2 (g) of the Employee's Provident Funds Scheme. 1952 and shouldI acquire a
family thereafter the above nomination should be deemed as cancelled.
2. .• certified that my father I mother is I are dependent upon me.

(") strike out whichever is not applicable. r>, .

I~~ ~d'~& .
e(~IGNATURE OR THUMB IMPRESSION OF THE SUI3SCRIBER

•
 PART - B (EPS)
Para 18'
I hereby furnish below particulars of the members of my family who would be eligible to receive widow I children Pensionin the event
of my death.

Sr.
No. Name & Address of the family member/s Date of
Birth , I
I Relationship with
Member
(1 ) (2) (3) (4)

"

*. Certified that I have no family, as defined in para 2 (vii) of tile Employees' Pension Scheme, 1995 and should.
~I acquire a family hereafter I shall furnish particulars thereon in th above form.

I hereby nominate the following person for receiving the monthly family pension (admissible under para 16(2)(i) and (ii) inthe event of
my death without leaving any eligible family rnernber/s for receiving pension.

Name & Address of the Nominee Address Date of Sinh Relationship with Member

(1 ) (2) (3) (4)

Date: _

(*) strike out whichever is not applicable

as,'\~
SIGNA URE OR THUMB IMPRESSION OF THE SUBSCRIBER

CERTIFICATE BY EMPLOYER
CERTIFIED that the above declaration an nomination has been signed I thumb impressed before me
by: Shri / Smt. / Miss. _

employed in my / our 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. f1

Place : _

Signature of the Employer's OR other Authorised

Date: _
Officer's of the Establishment
Signature with designation
RSFSRWS

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(narm and address of 111(, f;lctory i ,,=,I! or rlJblJ0.rstamp thereof)

..