THIS FORM IS SUPPLIED FREE OF COST.

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FORM-2 (Revised)
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NOMINATION AND DECLARATION FORM
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FOR UNEXEMPTEDfEXEMPTED ESTABLISHMENTS
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Declaration and Nomination Form under the Employees' Provident Funds & Employees' Pension Scheme
(~~f.mH~m 1952 ~tlu 33 3fu:61(1) ll:'i~~m 1995 CfiTtlu 18)
[Paragraph 33 & 61 (1) of the Employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employees'·
Pension Scheme, 1995]

1. ~(~~~)
Name (in Block Letters)

2. iitrr /~ COT ~

Name of the Parent/Spouse

3. ~fttfu 7. l«lT / Address

Date of Birth
~
Permanent

4. furl
Sex
~
5. ~f?'~ Temporary

Marital Status

6. ~ f.rfu\SffifT ~. ~br. / 8. Date of Joining

P. F. Account No. : A.PJ the Fund

$.TT1T-Cfj (ctitlinfl ~f.tfi.T) / PART-A (EPF)

11JlG[ml1~(m)q;)~/-w..CWfTt 3fu:~~m~~Gm~~.~.(m) q;) 3ltR~~~~ ~f.rfu
urn >rrn <08 ~ ~ ~ CWfTt I
I hereby nom:nate t:,e person(s)/cancel the nomination made by me previously and nominate the person(s), mentioned below to
receive the amount standing io my credit in the Employees' Provident Fund, in the event of my death.

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Name & Address of the Nominee / Nominees
Nominees' 'ilI:r.m-rr \WII
If the Nominee is a minor,
relationship Date of Birth .
Total amount or name, relationship &
with the share of accumu- Address of the guardian
Member lations in Provident who may receive the
Fund to be paid Amount during the
to each nominee. minority of nominee.
1 2 3 4 5

* ~ f<f;<n ~ ~ fq;~ \lfcMmm ~ 1952 -qm'lfu 2(6) it ~-ijuq;f{

'litem:~ ~ 31l\ ~ ~ ~ -iju~ 'litem: men ~ (f) mtm ~ «.~ ~ I
* 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 here~fter the above nomination should be
declared as cancelled.
2 * ~~~~~'~fun/rmn~'lolTf"-lO~1 ~$~llR~
* Certified that my father/mother is/are dependent upon me. 3ir@ 1fiT f.mR
* ;;f\ ffi1l~ hu CfiTl ~ I Signature or Thumb Impression
* Strike out whichever is not applicable. of the Subscriber
 rsfTJS -'& (t.rft.~.) (m18)/ PART-B (EPS) (Para 18)
~ ~ ~ -qftcm~~ 'fiT~~ ~Wlt-;;TI~~mcfitGm-ijfcNqr/~ ~>mI ~ ~ -qT;{~ I
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.

~~m2f~1l
Sli.K . 'l"ftcrn ~ ~ <fiT ;rp:f "If(ff ~fum Relationship with
S.No. Name of the family members Address Date of Birth Member

** >rtrTfUra f<f;<rr ~ ~ ~ mRt ~ ~ 1995 -ijlli\~~ 2( 7) ~ ~ ~ cnW -qftcm ~ ~ 3fu:«fG~ M~ cnW

mcrn:5trr~m~~1Wf-ij~~~cWrr I
** Certified that I have no famHy, as defined in para 2(vii) of the Employees' Pension Scheme, 1995 and should I acquire a family
hereafter I shall furnish particulars thereon in the above form.
it~ ~~mcfitGm-ij~ 1'6(2)(CIi)(I) 3fu: (11) ~3ltffi~ll'lfuq;~~~~';JW«Pfi\ffit~~ ~
~ >mI~ CITffi -qftcm'fiTcnW ~ ~ ~ !
(hereby nominate the following' person for receiving the munthly pension (admissible under para 162(a) (i) & (ii) in the event of my
death without leaving any eligible family member for receiving pension.

;rrftR! CfiT ';{Tl[ afu: 'qQT ~fum ~~m2f~

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

** ~ ffi'l;rlff ~ Cfi1G ~ I .~ ~ ~a.:R 3l~ al'@<trfun;{

** Strike out which is not applicable. Signature or thumb impression of the subscriber

f.%41'd'i1 "[RT~"q";f / CERTIFICATE BY EMPLOYER

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;r ~ mt ~ -ij CfiIfu ~ ~ Wl'P;l~a.:R/~ 'fiTf.mr;{ wmrr i I~ ~ q;) ~ i I ~~ Wl'P;l~ am ~ llt 3fu:
'3tR~~cfHI
Certified that the above declaration and nomination has been' signed I thumb impressed before me by
Shn/Smt.lKum'-- employed in my establishment

after he/she has read lhe entries/entries have been read over to him/her by me and got contimied by him/her.

~~~~3Pi~~~~l!R'
Signature of the employer or other
~:
allthorised Officers of the .establishment.
Place:

~:
Designation:
~:
Date: ~~'fiT1lll3fR~ ~~~cfit~
Name & Address of the FaclorylEstablishment
or Rubber Stamp thereof.