FORM -2 (REVISED)
A/C. Group No. __________
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED / EXEMPTED
ESTABLISHMENTS
________________________________________________________________
Declaration and Nomination Form under the employees’ Provident Funds (EPF) and Employees’ Pension Scheme (EPS)
(Paragraph 33 & 61(1) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’ Pension Scheme, 1995)
Name(In Block Letters):
Date Of Joining in EPF ’52 :
Father’s/Husband Name :
Date Of Joining in E.P.F. ‘71/E.P.S. ‘95
Date Of Birth :
Permanent Address :
Sex :
Temporary Address :
Marital Status :
Account No. :
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 Nominee / Nominees
Address
Nominee’s relationship with the member
Date of Birth
Total amount
of share of accumulations
in Provident
Fund to
Be paid to each nominee.
If the nominee
is a minor,
Name & relationship & address
of the guardian who may
receive the amount
during the minority of nominee.
1
2
3
4
5
6
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 may father / mother is/are dependent upon me.
Signature or Thumb impression of the subscriber
Strike out whichever is not applicable
PART-B (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.
Name & Address of the Family Member
Date Of Birth
Relationship with member
Sr. No
Name
Address
1
2
3
4
5
1
2
3
4
5
1.
Certified that I have no family 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.
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 the Nominee
Date Of Birth
Relationship with member
Date: Signature or Thumb impression of the subscriber
Strike out whichever is not applicable
CERTIFICATE BY EMPLOYER
Certified that the above declaration 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.
Place: Signature of the employer or other authorized
Officers of the establishment
Dated: Designation
Name & Address of Factory / Establishment and Rubber Stamp thereof