PHILIPS

Instructions to be followed:
1. Print this document and fll it in original. Once filled, upload ascanned copy as an
attachment on Workday.
2. There is a total of 03 signatures required in this document. Please ensure you sIgn m a
the places require.
employer".
3. Please leave the last section on Page 3 blank "Certificate by
GRATUITY, please ignore point number 5 and 6.
4. In the page (6) NOMINATION FOR
blank-"Declaration by witnesses",
5. Please leave the last 03 sections on Page 6
"Certificate by the employer" and "Acknowledgement by
the employee".
 PHILIPS
NOMINATION & DECLARATION
NOMINATION AND DECLARATION FORM
FOR UNEXEMPTED /EXEMPTED ESTABLISHMENTS
Declaration and nomination Form under the Employee'sProvident Funds &Employee's Pension Scheme.
Paragraph 33 & 61 (1) of the Employee's Provident Fund Scheme 1952, &Paragraph 18 of the
Employee's Pension Scheme. 1995

1. Name (in block letter)

2. Father's /Husband's Name VIGNESH CV.
3. Date of Birth
5. Marital Status
4. Sex:fNOLE
7. Address Permanent
UNHORRGD 6. Account No:
Loo9399494 2
CChaol¡imu
hoalalom heoi
o a o8600g4
8. Address Temporary A 28/
Chenoa 600094
PART-A (Employee's Provident Fund)
Ihereby nominate the person (s) cancel the nomination made by me previously nominate the person (s)
mentioned below to receive the amount standing to my credit in the Employee's Provident Fund, in the
event of my death:
Name & address Nominee's Date of Total amount If the nominee is a minor
of the nominees Relationship with Birth share of name, relationship
the member accumulations address of the guardian
in Provident who may receive the
Fund to be paid amount during the
to each minority of nominee
nominee

BINDHU T No THER No 88/ Necrqaa

1976

(a) Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme,
1952 and should I acquire a family hereafter the above nomination should be deemed as cancelled.
(b) Certified that my father / mother is a dependent upon me.
(c) Strike out whichever is not applicable.

Signature or thuigbjmpression
of the subscriber

2
 PART-B (Employee's Pension Schemne)
PHILIPS
Thereby furnish below particulars of the members of my family who would be
children Pension in the event of my death. eligible tO receive widow /
Name &Address of the family member
Date of Birth Relationship with the member

Chonoa booc

Certified that I have no family, as defined in para 2 (vii) of Employee's

Pension Scheme, 1995 and acquire
a family hereafter I shallfurnish particulars thereon in the above
form.
PART-B (Employee's Pension Scheme)
Ihereby nominate the following person for receiving the monthly
16 (2) (a) (1) & (i1) in the event of my death without leaving widow pension (admissible under para
any eligible family member for receiving
pension.

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

Bindha V
HoRor

Date

Strike out whoever is not applicable.

Signature or thumb impresyion of thesubscriber
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been
Shri / Smt/ Kmn signed / thumb impressed before me
after he /she has read the entries /the entries have been read employed in my establishment
over to him / her by me and got confirmed
by him / her.
Place:
Signature of the employer or other
authorized officer of the establishment
Dated:
designation
Name &address of the Factory/
Establishment or under stamp thereof

3
 NOTE: WHOM YOU CAN NOMINATE
(A)UNDER THE EMPLOYEE'S PROVIDENT FUND SCHEME
PHILIPS
(1) Amember of EPF who is married and/ or his father / mother is / are
nominate only one or more person belonging to his family as defined below:dependent upon him can
(2) In the case of a female member, her husband, her children, her dependent
dependent parents her deceased son's widow and children. parents, her husband's

2) If the member has got no family, or is a bachelor, nomination

whichever related to him or not or even to an institution. Ifthemay be in favor of any person or person's
member
such nomination shall forthwith become invalid and the subsequently acquires a family
member should make a fresh nomination in
favor of one or more person belonging to his family.
(B) UNDER THE EMPLOYEE'S PENSION
SCHEME:
(1) On the death of a member of the Employee's Pension
under the Employee's Pension Scheme. The family is Scheme, his family will be entitled to the benefits
defined as under.
(a) Wife in the case of a male member of Employee's
Pension Scheme: -
(b) Husband in the case of a female member of EP; and
(c) Minor sons and unmarried daughter of a member of the
EPS. Explanation: The expression "sons" &
"daughter" shall include children adopted legally before death in service. If the member has got no
family the monthly family person, on the death of the member,
Assurance Benefit will be paid to the person or persons entitledwill to
not be paid. However, Life
accumulation. receive his Provident Fund

A
 NOMINATION FORGRATUITY
PHILIPS
Payment of Gratuity
(SEE SUB-RULE () OF RULE 6)
FORM 'F

See sub-rule (1)of Rule7

Nomination

To, PHILIPS GLOBAL BUSINESS SERVICES LLP

(Mention name or description of the establishment with full address)

11, Shri/Smt/Kùmari
(Name in full here)
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 shall be paid in proportion indicated against the
name(s) of the
nominee(s).

2. Ihereby certify that the person(s) mentioned is/are a 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 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.

(b) My husband's father/mother/parents is/are not dependent on my
husband.
5. Ihave excluded my husband from my family by a notice
dated the

to the controlling authority in terms of the proviso to clause

(h) of Section 2 of the said Act.
6. Nomination made herein inyalidates my previous
nomination.
Nominee(s)

Name in full with full

Relationship with Age of Proportion by which
address of nominee(s) the employee nominee the gratuity will be
shared

1
|8odhu |Ychen- boo094 otke
2

3.

5
 PHILIPS
NOMINATION FOR GRATUITY (Continued)
Statement
full.YYA.AALESHCV.
1.
Name of employe in
2. Sex.
3. Religion...=HINDU
4. Whether unmarried/married/widow/widower.....RRGD.

5. Department/Branch/Section where employed...

6. Post held with Ticket No. or Serial No., if any....
7. Date of appointment:
8., Permanent address:
Cholgi
Village.apyhana..
YsesacchaAlagas. Rechaslauinsu
.Sub-division..
Post Ofice..ealaiauDistrict..h2NA. State..a.NodPina..Pin..6oog?4

Place:
Chana'
Signature/Thumb-impressio
of the Employee
Date: A
Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1

2 2

Place:. Date:

Certificate by the Employer

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

Employer's Reference No., if any Signature of the employer/0fficer authorized

Designation

Date: Name and address of the establishment or

rubber stamp thereof.

Acknowledgement by the Employee

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

Date: Signature of the Employee

Note. -Strike out the words/paragraphs not applicable.