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    FORM - 2 (Revised)

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    rohit.kedare
    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It contains sections for the employee to provide personal details and nominate individuals to receive the funds in their accounts in the event of their death. Section A allows nomination of beneficiaries for the provident fund. Section B requests family details for pension eligibility and nomination of a beneficiary to receive widow pension. The employer must certify that the employee completed and signed the form.

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

    FORM - 2 (Revised)

    Uploaded by

    rohit.kedare
    240 views2 pages
    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It contains sections for the employee to provide personal details and nominate individuals to receive the funds in their accounts in the event of their death. Section A allows nomination of beneficiaries for the provident fund. Section B requests family details for pension eligibility and nomination of a beneficiary to receive widow pension. The employer must certify that the employee completed and signed the form.

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    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It contains sections for the employee to provide personal details and nominate individuals to receive the funds in their accounts in the event of their death. Section A allows nomination of beneficiaries for the provident fund. Section B requests family details for pension eligibility and nomination of a beneficiary to receive widow pension. The employer must certify that the employee completed and signed the form.

    Copyright:

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

    FORM - 2 (Revised)

    Uploaded by

    rohit.kedare
    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It contains sections for the employee to provide personal details and nominate individuals to receive the funds in their accounts in the event of their death. Section A allows nomination of beneficiaries for the provident fund. Section B requests family details for pension eligibility and nomination of a beneficiary to receive widow pension. The employer must certify that the employee completed and signed the form.

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    © All Rights Reserved
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    FORM - 2 (Revised)

    NOMINATION AND DECLARATION FORM


    For Unexempted/Exempted Establishment
    Declaration and Nomination Form under the Employee's Provident Fund & Employees' Pension Scheme
    ( Paragraph 33 & 61(1) of the Employees' provident Fund Scheme, 1952
    & Paragraph 18 of the Employees' Pensio Scheme, 1995)

    1. Name ( in Block Letters)


    2. Father's / Husband's Name
    3. Date of Birth
    4. Sex
    5. Marital Status
    6. Account No.
    7. Address Permanent

    Temporary

    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.
    Total amount or
    If the Nominee is a minor,
    share of
    Nominee's name & relationship &
    accumulations
    Name of the relationship Date of Address of the guardian
    ADDRESS in Provident
    Nominees with the Birth who may receive the
    Fund to be
    Member amount during the minority
    paid to each
    of Nominee
    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 my Father / Mother is / are dependnt upon me

    * Strike out whichever is not applicable Signature or Thumb Impression of the Subscriber

    P.T.O.
    PART - B (EPS)
    (Para 18)

    I hereby furnish below Particulars of the Members of my Family who would be elogible to receive
    Widow / Children Pension in the event of my Death

    Sr. Name And Address of the Family Date of Relationship with


    No. Member Birth Member
    1 2 3 4

    *Certified that I have no Family, as defined in para 2 ( vii ) of Employees' Pension Scheme, 1995
    and should I acquire a Family herafter 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

    Date of
    Name and Address of the Nominee Address Relationship with the Member
    Birth
    (1) (2) (3) (4)

    Date :

    *Strike out whichever is not applicable Signature or Thumb Impression of the subscriber

    CERTIFICATE BY EMPLOYER
    Certified that the above Declaration and Nomination has been Signed / Impression before me by
    Shri / Smt / Kum.
    employed in my estblishment after he / she has read the entries / entries have been read over to him /
    her by me and got confirmed by him / her.
    Place :

    Date : Signature of the Employer or other Authorised Officers


    of the Establishment

    Name and Address of the Factory / Establishment or Rubber Stamp therof :

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