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Form 2

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shubham39naharwal
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38 views2 pages

Form 2

Uploaded by

shubham39naharwal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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EMPLOYEES PROVIDENT FUND ORGANISATION

NOMINATION AND DECLARATION FORM FORM 2 (REVISED)


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)

1. Name (IN BLOCK LETTERS) : 6. Account No. KN/BN :

2. Father's/Husband's Name : 7. Permanant Address :


, ,
3. Date of Birth :

4. *Sex : MALE / FEMALE : 8. Temporary Address :


, ,
5. Marital Status :

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.

Nominee Name Address Relationship Date of Birt Total amount of share of Accumul Nominee is minor
h ations in Provident Fund to be p
aid to each nominee

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.

Strike out whichever is not applicable Signature/or thumb impression of the subscriber

FOR OFFICE USE ONLY

Dt. of Joining E.P.F / /20 ENTRIES VERIFIEDE


Past Service .............................. Year
Dt. of Joining E.P.S / /20 D.A S.S A.A.O
PART - I ( 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 death:-

Nominee Name Address Relationship Date of Birt Total amount of share of Accumul Nominee is minor
h ations in Provident Fund to be p
aid to each nominee

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 (g) (i) & (ii) in the

event of my death without leaving any eligible family member for receiving pension.

Nominee Name Address Relationship Date of Birt Total amount of share of Accumul Nominee is minor
h ations in Provident Fund to be p
aid to each nominee

Date :-

Strike out which ever is not applicable

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.

/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.

Signature of the employer or other authorised Officers of the establishment.

Designation

Date the .................... Name & Address of the Factory / Establishment or rubber stamp there of

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