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PF - Form - 2

This document is a nomination and declaration form for an Employees' Provident Fund. It contains sections for nominating beneficiaries to receive the subscriber's PF accumulation amount in the event of death. It also collects details of family members eligible for pension payouts. Key details include: - Sections to provide the subscriber's personal details and nominate 1-5 beneficiaries for their PF by name, relationship, and share of accumulation. - A section to furnish details of family members eligible for widow/widower or children's pension by name, address, date of birth, and relationship. - Certifications if the subscriber has no family or dependents. The form is signed by the

Uploaded by

Mohan Kumar YLG
Copyright
© © All Rights Reserved
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Download as DOC, PDF, TXT or read online on Scribd
350 views

PF - Form - 2

This document is a nomination and declaration form for an Employees' Provident Fund. It contains sections for nominating beneficiaries to receive the subscriber's PF accumulation amount in the event of death. It also collects details of family members eligible for pension payouts. Key details include: - Sections to provide the subscriber's personal details and nominate 1-5 beneficiaries for their PF by name, relationship, and share of accumulation. - A section to furnish details of family members eligible for widow/widower or children's pension by name, address, date of birth, and relationship. - Certifications if the subscriber has no family or dependents. The form is signed by the

Uploaded by

Mohan Kumar YLG
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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EMPLOYEES’ PROVIDENT FUND ORGANISATION

Form No. (Revised) 2


NOMINATION AND DECLARATION FORM
FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees’ Provident Funds & Employees’ Pension Scheme
(Paragraph 33 & 61 of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the
Employees’ Pension Scheme, 1995)

1. Name (in block letters)…………………………………….. 6. Account No. KN/ /

2. Father’s / Husband’s name…………………………………… 7. Permanent Address:

3. Date of Birth………………………………………………..

4. Sex: ………………… Male Female Temporary Address:

5. Marital Status……………………………………………….

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:
If the Nominee is a
Total amount of
minor, name,
share of
relationship & address
Nominee’s relationship accumulation in
Name & Address of the Nominee/s Date of Birth of the guardian who
with the member Provident Fund to
may receive the
be paid to each
amount during the
Nominee
minority of Nominee
1 2 3 4 5

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 dependent upon me.


* Strike out whichever is not applicable Signature or thumb impression of the subscriber
__________________________________________________________________________________________
FOR OFFICE USE ONLY
Date of joining E.P.F / /19 ENTRIES VERIFIED
Past Service ________ year
Date of joining EPS / / 19 D.A S.S. A.A.O
PART – B (EPS) Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow / Widower /
Children Pension in the event of my death: -

Sl.No. Name of the family member Address Date of Birth Relationship with member
1 2 3 4 5

**Certified that I have no family, as defined in para 2 (vii) of 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 Pension (admissible under para 16 (2) (g) (i) & (ii)
in the event of my death without leaving any eligible family member for receiving pension.

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

Date:

*Strike out which ever is not applicable. Signature or thumb impression of the subscriber

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed /thumb impressed before me by
Shri/Smt./Kum………………………………………………………………………………employed
in my establishment after he /she has read the entries/ entries have been read over to him/her by me
and got confirmed by him/her.
Place : Bangalore
Date:

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