(FORM 2 REVISED)
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)
Fill Fill Fill
1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________
Name Father’s / Husband’s Name Surname
Fill
2. Date of Birth : ___________________ 3. Account No. ___________________
Fill
4. *Sex : MALE/FEMALE: ______________________ Fill
5. Marital Status ________________________________________
Fill here full address along with pin code
6. Address Permanent / Temporary : _____________________________________________________________________________
________________________________________________________________________________
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.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee
1 2 3 4 5 6
Enter
Full Mention DOB Total Write NA if
nominee
address relation of proportion nominee
details
of nominee should be is not minor
Can nominate
nominee 100%
dependent
parents,spouse,
children etc.
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.
Sign (whatever the marital status may be)
Strike out whichever is not applicable Signature/or thumb impression
of the subscriber
PART – (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 premature death in service.
Sr. No Name & Address of the Family Member Age Relationship with the member
(1) (2) (3) (4)
Fill if you are married, If single- Age Mention relationship
leave this table blank of
Can nominate spouse/ nominees
children etc.
Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.
Name and Address of Date of Birth Relationship with member
the nominee
Fill if you are unmarried DOB of Mention relation with
Can nominate any one person nominee nominee
e.g. mother/ father
Date of joining
Date ___________________
Sign (whatever the marital
status may be)
Signature or thumb impression
of the subscriber
____________________________________________________________________________________________________________
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./
Miss_________________________________________________________________ employed in my 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.
Date : _____________________ Signature of the employer or other authorised officer of the
establishment
Place :
Name & address of the Factory /Establishment
Date :
