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    Provident Fund Nomination Form

    Uploaded by

    koddati nithish
    This document contains a nomination and declaration form for D.E. Shaw India Private Limited Provident Fund. [1] It requests information such as the employee's name, father/husband's name, date of birth, sex, marital status, account number, and address. [2] The employee nominates individuals to receive their Employees' Provident Fund accumulations in the event of their death and provides each nominee's name, address, relationship, date of birth, and share of the total accumulation. [3] For married employees, it also requests family details like names, addresses, dates of birth, and relationships of those eligible for widow/children's pension upon the employee's death.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Provident Fund Nomination Form

    Uploaded by

    koddati nithish
    93 views2 pages
    This document contains a nomination and declaration form for D.E. Shaw India Private Limited Provident Fund. [1] It requests information such as the employee's name, father/husband's name, date of birth, sex, marital status, account number, and address. [2] The employee nominates individuals to receive their Employees' Provident Fund accumulations in the event of their death and provides each nominee's name, address, relationship, date of birth, and share of the total accumulation. [3] For married employees, it also requests family details like names, addresses, dates of birth, and relationships of those eligible for widow/children's pension upon the employee's death.

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    Provident_Fund_Nomination_Form

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    This document contains a nomination and declaration form for D.E. Shaw India Private Limited Provident Fund. [1] It requests information such as the employee's name, father/husband's name, date of birth, sex, marital status, account number, and address. [2] The employee nominates individuals to receive their Employees' Provident Fund accumulations in the event of their death and provides each nominee's name, address, relationship, date of birth, and share of the total accumulation. [3] For married employees, it also requests family details like names, addresses, dates of birth, and relationships of those eligible for widow/children's pension upon the employee's death.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    93 views2 pages

    Provident Fund Nomination Form

    Uploaded by

    koddati nithish
    This document contains a nomination and declaration form for D.E. Shaw India Private Limited Provident Fund. [1] It requests information such as the employee's name, father/husband's name, date of birth, sex, marital status, account number, and address. [2] The employee nominates individuals to receive their Employees' Provident Fund accumulations in the event of their death and provides each nominee's name, address, relationship, date of birth, and share of the total accumulation. [3] For married employees, it also requests family details like names, addresses, dates of birth, and relationships of those eligible for widow/children's pension upon the employee's death.

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    © All Rights Reserved
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    FORM - 2 (Revised)

    NOMINATION AND DECLARATION FORM


    D. E. SHAW INDIA PRIVATE LIMITED PROVIDENT FUND

    Declaration and Nomination Form under the Employees' Provident Funds


    And 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 : 6. Account No. : AP/HY/32184/


    Letters)

    2. Father's / : 7. Address :
    Husband's Name
    Permanent :
    3. Date of Birth :

    4. Sex : Temporary :

    5. Marital Status : 8. Date of


    Joining

    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.

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


    Nominee Relationship Birth Share(%) of Minor, Name and
    Nominees With the Accumulations in Relationship and
    Member Provident Fund Address of the Guardian
    to be Paid to each who may Receive the
    Nominee Amount During the
    Minority of Nominee
    1 2 3 4 5 6

    1. * Certified that my father / mother is / are dependent upon me.


     Strike out whichever is not applicable.

    Signature of the subscriber


    PART - B (EPS)
    (Para 18)

    (To be filled by married employees)

    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.

    S. No. Name and Address of the Family Member Date of Birth Relationship with
    Name Address Member
    1 2 3 4 5

    1.

    2.

    3.

    (To be filled by unmarried employees)

    ** Certified that I have no family, as defined in para 2(vii) of the Employees' Pension Scheme, 1995 and Comment [v.s.p1]:
    should I acquire a family hereafter I shall furnish particulars thereon in the above form. Para 2 (vii) of the Employees
    Pension Scheme defines family

    in the case of male member, his wife


    in the case of female member, her
    I hereby nominate the following person for receiving the monthly pension (admissible under para 16 2(a) (i) husband,
    & (ii) in the event of my death without leaving any eligible family member for receiving pension.
    sons and daughters of a
    Name and Address of the Nominee Date of Birth Relationship with the Member member(male or female)
    of the Employees Pension Fund.

    Date:

    Signature of the subscriber

    ** Strike out whichever is not applicable.

    CERTIFICATE BY EMPLOYER

    Certified that the above declaration and nomination has been signed before me by
    Shri / Smt. / 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: Hyderabad
    Date: Signature of the employer or other
    Authorised Officers of the establishment
    Designation: Director
    Name & Address of the Factory /
    Establishment or Rubber Stamp thereof.

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