Form 2 (Revised)

NOMINATION AND DECLARATION FORM

(For Unexempted/Exempted Establishments)
Declaration and Nomination Form under the Employees' Provident Funds & Employees' Pension Scheme
(Paragraphs 33 & 61(1) of the Employees' Provident Fund Scheme, 1952 and Paragraph 18
of the Employees' Pension Scheme, 1995 )
1. Name (in block letters) :

2. <Q NA>

3. Date of Birth : 4. Sex :

5. Marital Status : 6. Account No. :

7. Date of Joining : 8. Employees (PS ID) No :

9. Address:
(1) Permanent :
(2) Temporary :

Part A (EPF)
I hereby nominate the person(s) / cancel the nomination made by me previously and nominate the person(s),
mentioned below receive

Name of the Address Nominee's Date of Total If the nominee is a

nominee / relationship Birth amount or minor, name &
nominee's with the share of relationship & address
member accumulati of the guardian who
ons in may receive the amount
Provident during the minority of
Fund to be nominee
paid to
each
nominee
1 2 3 4 5 6

1. *Certified that I have no family as defined in Pare 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 / are dependent upon me.

_____________________________________
Signature or thump impression of the Subscriber
 PART B (EPS)
(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible to recieved widow/ children pension
in the event of my death.
Sr.No. Name of the Address Date of Relationship
Family member Birth with member
1 2 3 4 5

** 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 nominated the following person for receiving the monthly widow pension (admissible under para 16 2(a) (I) & (II) in
event of my death without leaving any eligible family member for receiving pension.

Name & Address of the nominee Date of Birth Relationship with the member

Date:

Signature or thump impression of the subscriber

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Kum.
, employed in my establishment after he/she has read the entries have
been read over to him/her by me and got confirmed by him/her.

Signature of the employer or other

Authorized officers of the establishment:

Designation

Place Name and Address of Factory / NWM Services India Private Limited
1st Floor, Tower A, Building No. 1,
Establishment or Candor Techspace, IT/ ITES SEZ, Sector 21,
rubber stamp thereof: Gurgaon 122016, Haryana, India
 FORM 'F'
[See sub-rule(1) of rule 6]
NOMINATION

To, NWM Services India Private Limited

Registered Office: 1st Floor, Tower A, Building No. 1, Candor Techspace, IT/ ITES SEZ, Sector 21, Gurgaon
122016, Haryana, India

1. I, Shri/ Shrimati/ Kumari

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 shall be paid in proportion
indicated against the name(s) of the nominee(s).

2. I hereby certify that the person (s) mentioned is/are member (s) of my family within the meaning of
clause (h) of Section 2 of the Payment of Gratuity Act, 1972.

3. I, hereby declare that I 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.

/ parents is / are not dependent on my husband.

5. Nomination made herein invalidates my previous nomination.

NOMINEE(S)

Proportion of
Name in full with address of Relationship with
Age of nominee which the gratuity
Nominee (s ) the employee
will be shared
1 2 3 4
 STATEMENT

1. Name of employee in full :

2. Sex :
3. Religion :
4. Whether unmarried/ married/ widow/ widower :
5. Department / Branch / Section where employed :
6. Post held with Emp.No. or, Serial No. if any. :
7. Date of appointment :
8. Permanent address :

Plac`e :
Date :
_____________________
Signature of the employee

Declaration by witness
Signed before me
Name and address in full of the witness Signature of the witness

1. Name 1.

2. Address C/o NWM Services India Private Limited

1. Name 2.

2. Address C/o NWM Services India Private Limited

Place:
Date:

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer's Address
NWM Services India Private Limited
Registered Office: 1st Floor, Tower A, Building No. 1, Candor Techspace, IT/ ITES SEZ,
Sector 21, Gurgaon 122016, Haryana, India
_________________________
Date: Signature of the employer/officer authorized
Designation:

Acknowledgment by the employee

Received the duplicate copy of nomination in Form 'F' filled by me and duly certified by the employer.

Date:

Signature of the employee

 www.epfindia.gov.in
Composite Declaration Form -11
(To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995 is applicable)

1 Name of the member

<Q NA>
Father's Name *
2 Spouse's Name *
(Please tick whichever is applicable)
3 Date of Birth: ( DD / MM / YYYY )
4 Gender: (Male/Female/Transgender)
5 Marital Status: (Married/Unmarried/Widow/Widower/Divorcee)
(a) Email ID:
6
(b) Mobile No.:
Present employment details:
7
Date of joining in the current establishment (DD/MM/YYYY)
KYC Details: (attach self attested copies of following KYCs)
a) Bank Account No. : b) IFS Code of the branch:
8
c) AADHAR Number
d) Permanent Account Number (PAN), if available
Whether earlier a member of Employees' Provident Fund
9
Scheme,1952
Whether earlier a member of Employees' Pension Scheme,
10
1995
Previous employment details: [if Yes to 9 AND/OR 10 above]- Un-exempted
Establishment Name & Universal PF Date of Date of Scheme PPO Non
Address Account Account joining exit Certificate Number (if Contributory
11
Number Number (DD/MM/ (DD/MM/ No. (if issued) Period
YYYY) YYYY) issued) (NCP) Days

Previous employment details: (if Yes to 9 AND/OR 10 above) - For Exempted Trusts

Date of Scheme Non

Member Date of exit
joining Certificate Contributory
Name & Address of the Trust UAN EPS A/C (DD/MM/
12 (DD/MM/ No. (if Period (NCP)
Number YYYY)
YYYY) issued) Days

a) International Worker:
b) If yes, state country of origin (India/Name of other country)
13
c) Passport No.
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)] -
 UNDERTAKING

1) Certified that the particulars are true to the best of my knowledge.

2) I authorize EPFO to use my Aadhaar for verification/authentication/e-KYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared
above to the present P.F. Account as I am an Aadhaar verified employee in my previous PF Account *
4) In case of changes in above details, the same will be intimated to employer at the earliest.

Place :
Date : Signature of Member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr/Ms/Mrs has joined on and has been allotted PF No and UAN

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:

Please Tick the Appropriate Option:

The KYC details of the above member in the UAN database

Have not been uploaded
Have been uploaded but not approved
Have been uploaded and approved with DSC/e-sign.

C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:

Please Tick the Appropriate Option:-

The KYC details of the above member in the UAN database have been approved with E-sign/Digital Signature
Certificate and transfer request has been generated on portal.
The previous Account of the member is not Aadhaar verified and hence physical transfer form shall be
initiated.

Date : Signature of Employer with Seal of Establishment

* Auto transfer of previous PF account would be possible in respect of Aadhaar verified employees only. Other employees
are requested to file physical claim (Form-13) for transfer of account from the previous establishment.