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    PF Form - 2

    Uploaded by

    suveg

    Copyright:

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

    PF Form - 2

    Uploaded by

    suveg
    9 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

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

    PF Form - 2

    Uploaded by

    suveg

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    Date of Appointment: ________________________

    (P.F. Deduction Date): ________________________ FORM 2 (REVISED)


    s

    NOMINATION AND DECLARATION FORM Group No.:


    FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
    Office:
    Declaration and Nomination Form under the Employees’ Provident Funds
    and Employees’ Pension Scheme

    (Paragraph 33 & 61 (1) of the Employees’ Provident Funds Scheme, 1952 and
    Para 18 of the Employees’ Pension Scheme, 1995)

    1. NAME (in block letters):_____________________________________________________________________

    2. FATHER’S/HUSBAND’S NAME:________________________________________________________________

    3. DATE OF BIRTH (dd/mmm/yy):_______________________________ 4. SEX:_________________________


    (DD/MMM/YY) (Male/Female)

    5. MARITAL STATUS:______________________________________________________
    (Unmarried/Married/Widow/Widower)

    6. PF ACCOUNT NO.:__________________________________________________

    7. ADDRESS:________________________________________________________________________________
    ________________________________________________________________________________

    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 amt. or If the nominee is minor,


    share of name, relationship & add. Of
    Nominee’s relationship with
    Name & address of the nominee (s) Date of Birth accumulation in the guardian who may
    the member
    PF to be paid to receive the amount during
    each nominee minority of nominee

    1. * Certified that I have no family as defined in para 2 (g) of the Employees’ Provident Funds Scheme, 1952 and should I
    acquire a family thereafter 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


    X___________________________________________
    SIGNATURE OR THUMB IMPRESSION OF THE SUBSCRIBER
    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.

    Sr.
    Name & address of the family member/s Date of Birth Relationship with member
    No.

    ** 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 family pension (admissible under para 16 (2) (i) and (ii) in the
    event of my death without leaving any eligible family member / s for receiving pension.

    Sr.
    Name & address of the nominee (s) Date of Birth Relationship with member
    No.

    Date:_______________________________
    X___________________________________________
    SIGNATURE OR THUMB IMPRESSION OF THE SUBSCRIBER

    CERTIFICATE BY EMPLOYER
    CERTIFIED that the above declaration and nomination has been signed / thumb impression before me
    by : Shri/Smt./Miss.________________________________________________________________________________________
    employed in my / our establishment after he / she has read the entries / the entries have been read over to him / her by me and
    got confirmed by him / her.

    Place:___________________________ _______________________________________
    Signature of the Employer’s OR other Authorized
    Date:____________________________ Officer’s of the Establishment
    signature with designation

    (name and address of the factory / estt. Or rubber stamp thereof)

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