NOMINATION AND DECLARATION FORM - …

1 1:2:3:4:5:6:7 Address Permanent:Temporary:8 Date of Joining:EPF:EPS:Nominee's relationshipDate of Total amount of share ofwith the memberBirthaccumalation in providentfund to be paid to each nominee234123 Unmarried members in the absence of dependent parents may nominate any other person to receive the sharesNote: A Fresh NOMINATION shall be made by the member on his/her marriage and any NOMINATION made before such marriage shall be deemed to be invalidaddress & relationship of theCertified that my father / mother is / are depended upon or thumb impression of the SubscriberFORM - 2 ( Revised) NOMINATION AND DECLARATION FORMFOR EXEMPTED / UNEXEMPTED ESTABLISHMENTSD eclaration and NOMINATION form Under the Employee's Provident Funds & Employees' Pension Scheme5(Paragraph 33 & 61 (1) of the Employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employees's Pension Scheme, 1995)Name ( In Block Letters)Name & Address of theif the nominee is minor name &Account NumberMarital StatusSexFather's / Husband's NameDate of BirthCertified that I have no family as defined in para 2 (g)

2 Of the Employee's Provident Fund Scheme 1952 and should I acquire a family hereafter the above NOMINATION should be deemed as cancelled1 PART - A (EPF)Iherebynominatetheperson(s)/cancelt henominationmadebymepreviouslyandperson( s)mentionedbelowtoreceive the amount standing to my credit in the Employees' Provident Fund, in the event of my who may recive the amountNominee/ Nomineesid35602968 pdfMachine by Broadgun Software - a great PDF writer! - a great PDF creator! - of BirthRelationship12345 Date of BirthDate :xPlace:Date :Signature of the employerName & Address of the EstablishmentName & Address of the NomineeRelationship with the memberSignature / Thumb impression of the subscriberName of the Family MembersAddressIherebynominatethefollowin gpersonforreceivingthemonthlywidowpensio n(admissibleunderpara16(2)(g)(I)&(ii) in the event of my death with out leaving any eligible family member for receiving - B (EPS)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 deathCertifiedthattheabovedeclarationand nominationhasbeensigned/thumbimpressedbe foreshri/Smt/Kum.)

3 Employedinmyestablishmentafterhe/shehasr eadtheentry/entrieshavebeenreadovertohim /her by me and got confirmed by BY EMPLOYERC ertifiedthatIhavenofamilyasdefinedinpara 2(vii)oftheEmployee'sPensionScheme1995an dshouldIacquireafamily hereafter the above NOMINATION should be deemed as cancell