JLARATION FORM sic 0 Fort a — von yng web ace wn om Tam neste fee Terman resco one 1 a ae | [stnsuane employers Coo Wo. 1 = aera — ET sewn oare sett sae & Aes oe earth Tle — omy | oe aa Soca met ee = ae a J oh ee ate te Lees erate min tot ne en ee a any wn ts apt eNO cone Signe api sigue ict AML PARTICULARS OF HEURED PERSON [wc repaint necro chon oo piers SE NOT aE Fa ~ x Shpatwe/ Tet ‘Sinaice of AM. wise © scanned with OKEN ScannerATUITY RULE, 1972 THe PAYMENT OF GR FORM-F (See sub-rule (1) of le ) Nomination te Wis eee 4. Sha/Shimati/Kumari_Ro salal 4 Cesare) mentioned belowto sate the ps ‘edit in the event of my i. sare givenin ie statement below, I ble after my death as also the g oe eat before thal amount has become payable, or having become ayes 1 seat a the said amount of gratuity shal be pain proportion in i nominee(s) mentioned isare member(s) of faiy within the meaning of 1972. tomy! tanding oY has not being paid and whose particulars the name(s) of the receive the gratuity payal 2. Ihereby‘certify that the person(s) clause(h) of section 2 ofthe Payment of Gratuity act, 3. _Inereby deciare that have no family within the meaning of clause(h) of section 2 of of the said act. 4, (a) My fathor/ mother! parents is! are not dependent on me. (b) My husband's father mother! parents is/are not dependent on my husband. 5. Ihave excluded my husband from my family by anotice dated the, tothe controlling authority in terms of the provision to the clause(h) of section 2 of the said act. 6. Nomination made herein invalidates my previous nominations, | NOMINEE(S) Name in fll wih address || Relationsh 2 ine oF the nominees) cane. || mines wenn getty a oe @ will majees i I Ramlal Loddnd || Eathon \ Low's J [s 7 Ui { STATEMENT } (1. |] Retgon + Hindu } 2 || sox ie a woe MALE } 3. || Name of employee infu ott RA ROT LA DAD 4. ‘Whether unmarried/married/widowhwidower Wow oried © scanned with OKEN Scanneras um mpresion Place : Puine, Maherusthrs signature atlocles Signe employee: Date 2 ent DECLARATION BY WITNESSES Fresh nomination signedithumb impressed before me. ‘Name and full address of the witnesses. ———— Date CERTIFICATE BY THE EMPLOYER _ “afon have been verified and recorded in this establishment. particulars of the above nomin Certify that the 1ce No. If any: Employers referen signature of the employer! officer authorized. Designation : Date Name and address of the establishment ‘or rubber stamp therof ACKNOWLEDGEMENT BY THE EMPLOYER ~ duplicate copy of nomination in form “F” fled by me and duty cerfed by the employer ® S signature of the employee: Received tht pote: [210 \2025 Note : Strike out the words/paragraphs not applicable. © scanned with OKEN Scanneration Form -11 ympasite Declaration ed EMPLOYEES’ PROVIDENT F pil ee Lmplayes' Provident Funds Schemes 1952 ET 24) 1 25 195i aprbeabe nployees Pension Scheme, 995 (PATENT 9s andor {teats ing op et yeh oe ERT SASSS TTT D 1 [Nupbatucincatee ae par LAY Fae? s Name 2 | Sponse's ica A) — ou'sKame | Rampa LADD AD __ 3_ | Dac orb DP TMNT) yo lol sat 4 | Gender (ater cater Trnspeadely 00 ALE 5 | Mafia Stig arog atean nar ono U. soe rail toms ¢ [© Emilio: = yori t Laddad 43 0) Mobile Nos qac gree 7 | Bisset ecployment dear | 7 _| Pate otjoinine inte curent establishment (DDMMIYYYY) : YC Dela: (atal slFaed opis oF flowing RVC) a) Basie Account Nor? SLES YEE 8 |) 1SCode ofthe beck SIN 000 (932. ©) _AADHAR Number JoSTAM OF12 &) Pennant Account Nawiber @AN), ava AyDre 1363L. 9 | Whether earlier member of Employees" Rovident Fund Scha Yes 1 TO Whether caviers metiber of Eployea? Felon Stans, TODS Yee Previous emplaystent details: [I Veto} ANDIOR 10 shove] =Un-axcanpiad (ablshecs | Unieeal | PF Aca | Dae ofjoaug | Dazafeai | —Saene—[ PRO Namie” | — Now Named Adsess | Aecout | “Nanter” | (bom | ‘(oni | coutteze | Grund) | Contetory amb wenn | Swen) | Sve riod ‘ied (scr) ? "Hares W WovTes 73) s — Ee ne ~ 7660 Previous employment deta: ft Ves 09 ANDIOR 10 above —For Exeapied Trane Wane & Adiiess ofthe Trust| UAN | Manibor | Datcot | Daisofeak | ~Schane ] Now EPS Are | joining | Coo | Ceniteate | Contiutory Number | (opine | “YvvY) | “Nod” | period ver) YYYY) isued_| “Days R a) International Worker: Yerxe 13, |B) tyes sate connie of origin GndiName of oer court) = ) PassportNo % 4) Validity of passport [(DD/MMIYYYY) to (DDIMMIYYYY)] a © scanned with OKEN Scanneray UNDERTAKING 1) Conti 2 et tng et 48 oo ke of ay nla 3» Ki we my Aadtar for vrai ‘ny teaser he a it sotto RY peri ei dy Coun aT an Ane Se des, apie, fram the previous PF econ as dae ove he preset FF veto 9 Wesse of ang enoloyesin danger try peevios PF Aca ove dei, th same wil bam a eoplayer athe ea. dae, V2 o¢loor 5 nse , = Pune , Maharedlrn ieanieaevtee DECLARATION BY PRESENT EMPLOYER A. The meniber MeMeMes ann Alot PFNa sd far eet ee oi 00 BL Incase te person was eater not a ener of EP Seteme, 1952 and EPS, 1995: Please Tick the Appropriate Option: “TheKYC dots ofthe above tember i the UAN ditbese Have not Boo oplaaed Have boon uploaded bs at approved Have been uplondd and approved wid DSClesion Incase the person was earie'a emf of EPP Scheme, 1952 and EPS, 1995: + Please Tick the Appropciate Option: ees Cee err erin he UAN dass he bon eproed wit in Diia! Sizsare (Conical ad rans request has bon grcrated on portal ae ee eerie Aaa wd and ec py ttf lb eine, Signature of Ezployer with Seal of ‘Exsblchmest Auto wanster of provi PF aon wold be possible in spect of Aah veri eigen: Other emplayes ar request ‘He peta el Forn13) fc ranster of scout Fen te previous easiest, 7 © scanned with OKEN ScannerFORM 2 (Revised) NOMINATION AND DECLARATION FORM VOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS Desirton ad Nomination Form Under te Employes Provident Funds mlayees Penson Schemes (erapr0h 93 6169) othe Eton evident Pun Scheme, 19 Paragraph 3B ofthe Employes Pension Scheme, 955) Name (In Block Letters) RAMLAL Father's / Spouse's Name 3 Dateot iets 4 Sex 5 Marital status Account Number 7 Address Permanent “Gor Zale Supreme y Lane No-T Kayve Nagar Pune - Host 8 Dateof Joining L —_12\ oblaore ine) PART-A(EPF) Thereby nominate the Person(s) / cancel the nomination made by below to receive the a ¥y me previously and nominate the person(s) mentioned mount standing to my credit inthe Employees Provident Fund, inthe event ofp arte Tameonie ror Nonie’s [BRSTBRN | Felson | Tis none SRS Nominnts) sani wih sfshaeot slices ereaonhp ote Shemenber secumultion | juian wo may eine te ‘spree on fond nbepaid ‘wont 7 2 3 7 5 | t MeoL A Rombol Ladda) : Foon, pilot vot et H G y | © scanned with OKEN Scanner@ 3. *Certfied that Ihave no family as defined in para 2 acquire a famllyherestr he cbove nein arg Det the Employee's Provident und Seteme, 94nd shoud! i od be deemed as cancsled ‘Certified that my father / mother is / are depended upon me. "strike out whichever isnot applicable signature o thumb impression othe Subset PART-B (EPS) Para18 cewidow/childsen pension ‘Thereby furnish below particulars ofthe members ofmy femiy who woutd be eis receiv in the event of my premature death in service. ‘SNo|__Name of the Family Members 3| co 3 | af ‘scheme 1995 and should Kaomuire a sei Pension se degd np of ee! “ert that haven a astro nt above oe ae ‘under para 16 2 (2) (i) & Gi in the: ‘ 1 adninsble aera phang pwn orev nein ge nat at ca rigible family member for ree 1g Pe a ‘death without leaving ay cevent of my Fame & Address of the Nominee age signature / Thumb impression ofthe subscriber © scanned with OKEN Scanner