(FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

DECLRATION AND NOMINATION FORM UNDER THE EMPLOYEES PENSION SCHEMES
(PARAGRAPH 33 AND 61(1) OF EMPLOYEES PROVIDENT FUND SCHEME FUND SCHEME 1952 AND PARAGRAPH 18 OF THE
EMPLOYEES PENSION SCHEME 1995)

1. NAME : MAKWANA GOVIND HIMATBHAI

2. DATE OF BIRTH : 19/02/1996 5. ACCOUNT NO : GJAHD15610060000013673
3. SEX : MALE 6. MARTIAL STATUS : UNMARRIED
4. ADDRESS : NAVO HARIJAN VAS, SIHOR, BHAVNAGAR, GUJARAT, 364240

PART – A (EPF)
I HEREBY NOMINATION 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 EMPLOYEE PROVIDENT FUND,
IN THE EVENT OF MY DEATH.
1 2 3 4 5 6
IF THE NOMINEE IS
TOTAL AMOUNT
MINOR NAME AND
OR SHARE OF
NOMINEE’S ADDRESS OF THE
NAME DATE ACCUMULATIONS
RELATIONSHIP GUARDIAN WHO
OF ADDRESS OF IN PROVIDENT
WITH THE MAY RECEIVE THE
NOMINEE BIRTH FUND TO BE PAID
MEMBER AMOUNT DURING
TO EACH
THE MINORITY OF
NOMINEE
THE NOMINEE

MAKWANA HIMMATBHAI 09/11/1966

SIHOR FATHER 100%
DEHABHAI YEAR

1. CERTIFIED THAT I HAVE NO FAMILY AS DEFINED IN PARA 2 (g) OF THE EMPLOYEES PROVIDENT FUND SCHEME 1952 AND
SHOULD I ACQIRE 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 SUBCRIBER
PART – B (EPS)
PARA 18
I HEREBY FURNISH BELOW PARTICULARS OF THE MEMBER OF MY FAMILY WHO WOULD BE ELIGIBLE TO RECEIVE
WIDOW/CHILDREN PENSION IN THE EVENT OF MY PREMATURE DEATH IN SERVICE.
1 2 3 4

RELATIONSHIP WITH
SR NO NAME AND ADDRESS OF THE FAMILY MEMBER AGE
THE MEMBER

09/11/1966
1 MAKWANA HIMMATBHAI DEHABHAI FATHER
YEAR
 CERTIFIED THAT I HAVE NO FAMILY AS DEFINED IN PARA 2 (vii) OF THE EMPLOYEE’S FAMILY PENSION SCHEME 1995
AND SHOULD I ACQIRE A FAMILY HEREAFTER I SHALL FURNISH PARTICULARS THERE ON IN THE ABOVE FORM.

I HEREBY NOMINATE THE FOLLOWING PERSON FOR RECEIVING THE MONTHLY WIDOW (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 : 01/03/2023

SIGNATURE OR THUMB IMPRESSION

OF THE SUBCRIBER

CERTIFICATE BY EMPLOYER

CERTIFIED THAT THE ABOVE DECLARATION AND NOMINATION HAS SIGNED / THUMD IMPRESSED BEFORE ME BY
SHRI/SMT/MISS MAKWANA GOVIND HIMATBHAI EMPLYED IN MY ESTABLISHMENT AFTER HE/SHE HAD READ THE ENTRIES
/ THE ENTRIES HAVE BEEN READ OVER TO HIM/HER BY ME AND GOT CONFIRMED BY HIM/HER.

BHADRESHKUMAR R DAHE – HUF I-TECH PLAST INDIA PVT. LTD.

KARTA AUTHORISED SIGNATORY

DATE : 01/03/2023
NAME AND ADDRESS OF THE ESTABLISHMENT / FACTORY : I – TECH PLAST INDIA PVT. LTD.
SURVEY NO : 108/109 PAIKY 4,
BHAVNAGAR RAJKOT HIGHWAY,
SHAMPARA ( KHODIYAR ),
BHAVANAGAR – 364240.

PLACE : BHAVNAGAR DATE : 01/03/2023