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02 - EPF - Form - 2 Copy Fv1

The document is a nomination and declaration form for exempted and unexempted establishments under the Employee's Provident Funds and Employees' Pension Scheme. It includes sections for personal information, nomination of beneficiaries for provident fund and pension, and a certification by the employer. The form requires signatures and provides guidelines on the validity of nominations based on marital status and family definitions.

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Ganesh Tambe Patil
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72 views2 pages

02 - EPF - Form - 2 Copy Fv1

The document is a nomination and declaration form for exempted and unexempted establishments under the Employee's Provident Funds and Employees' Pension Scheme. It includes sections for personal information, nomination of beneficiaries for provident fund and pension, and a certification by the employer. The form requires signatures and provides guidelines on the validity of nominations based on marital status and family definitions.

Uploaded by

Ganesh Tambe Patil
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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FORM - 2 ( Revised)

NOMINATION AND DECLARATION FORM


FOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS
Declaration and Nomination Form Under the Employee's Provident Funds & Employees' Pension Scheme
(Paragraph 33 & 61 (1) of the Employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employees's Pension Scheme, 1995)

1. Name (In Block Letters)

2. Father's / Husband's Name

3. Date of Birth

4. Sex

5. Marital Status

6. Account Number

7. Address

7. Date of Joining

PART - A (EPF)
I here by nominate the person(s) / cancel the nomination made by me previously and person(s) mentioned below to receive
the amount standing to my credit in the Employees' Provident Fund, in the event of my death.

Name & Address Nominee's Total amount of share of If the nominee is minor name
Date accumulation in provident & address & relationship of
of the relationship with
of Birth fund to be paid to each the guardian who may receive
Nominee/ Nominees the member
nominee the amount

1 2 3 4 5

1. Certified that I have no family as defined in para 2 (g) of the Employee's 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.

3. Unmarried members in the absence of dependent parents may nominate any other person to receive the shares

Note : 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 invalid
Signature or thumb impression of the Subscriber
PART - 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 death

Sr. Name of the Family Members Address Date of Birth Relationship


No.

01

02

03

04
05

Certified that I have no family as defined in para 2 (vii) of the Employee's Pension Scheme 1995 and should I acquire a family
hereafter the above nomination should be deemed as cancelled
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 with out leaving any eligible family member for receiving pension.

Name & Address of the Nominee Date of Birth Relationship with the member

Date : Signature / Thumb impression of the subscriber

CERTIFICATE
BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before shri/Smt/Kum…………………….
.......................... employed in my establishment after he/she has read the entry/entries have been read over to him/her by me
and got confirmed by him/her.

Place :
Date : Signature of the employer

Name & Address of the Establishment

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