Ì348201-PFNOMJÎ

Employee Code: 348201

PF FORM - 2 (Revised)
NOMINATION AND DECLARATION FORM
For Unexempted/Exempted Establishment
Declaration and Nomination Form under the Employee’s Provident Fund & Employees’ Pension Scheme
(Paragraph 33 & 61(1) of the Employees’ Provident Fund Scheme, 1952
& Paragraph 18 of the Employees’ Pension Scheme, 1995)

1. Name (in Block Letters) :

Sanjana Deb

2. Father’s/Husband’s Name :
Sanjay Kumar Deb

3. Date of Birth :
17/09/1999

4. Sex :
Female

5. Marital Status :
Single

6. Account No :

7. Address Permanent :
51 B (5) Chandra Nagar ,Lal Banglow,, P O Harjinder Nagar,
Kanpur, Uttar Pradesh, India, 208001

Temporary :
51 B (5) Chandra Nagar ,Lal Banglow,,P O Harjinder Nagar,
Kanpur, Uttar Pradesh, India, 208001

8. Date of Joining :
18/09/2024

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.

Nominees Total amount If the

Name of The relationship Date of or share of Nominee
Address
Nominees with the Birth accumulations is a minor,
Member in Provident name
 Fund to be relationship
paid to each Address of
Nominee the guardian
who may
receive the
amount
during
the minority
of Nominee

51 B (5) Chandra Nagar ,Lal

Pampa Deb Mother 31/01/1982 100
Banglow,,P O Harjinder Nagar

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

X
Note: - A fresh nomination shall be made by
the member on his marriage and any
nomination made before such marriage shall Signature/Thumb impression of the employee (Subscriber)
be deemed to be invalid
 PART-B (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 death

Sr. No. Name and Address of The Family Member Date of Birth Relationship
With
Member

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

**Certified that I have no Family, as defined in Para 2(vii) of Employees’ Pension 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 family Pension [Admissible under Para 16 (2)
(a) (I) & (ii)] in the event of my Death without leaving any eligible Family Member/s for receiving Pension

Name of The Address Date of Birth Relationship

Nominee With the
Member

1 2 3 4

Pampa Deb 51 B (5) Chandra Nagar ,Lal Banglow,,P O Harjinder Nagar 31/01/1982 Mother
Date :15/07/2024

*Strike out whichever is not applicable X

Signature/Thumb impression of the employee (Subscriber)

CERTIFICATE BY EMPLOYER

Certified that the above Declaration and Nomination has been Signed/Impression before me by
Kum
Employed in my establishment after he/she has read the entries/entries have been read over to him/her by me and
got confirmed by him/her.

Place:Mumbai

Date :

For IDFC FIRST Bank Limited

Authorized Signatory

IDFC FIRST Bank Ltd, Naman Chambers,

C-32, G Block, BKC, Bandra (E), Mumbai - 4000051

Name and Address of the Factory/Establishment or Rubber Stamp thereof