Employee code _______________

(Mandatory )

FORM 2 (Revised)
(For Unexempted /Exempted Establishm ents)

NOMINATION AND DECLARATION FORM

(Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme)
(Paragraphs 33 & 61 (1) of the Employees’ Provident Funds Scheme, 1952 and paragraph 18 of the Employees’ Pension Scheme, 1995)

1 Name (in Block Letters) :

2 Father’s/Husband’s Name :
3 Date of birth :
4 Sex : Commented [AN1]: Mention UAN No only

5 Marital Status :
6 Account No. (PF/EPS Number) : 7
Address (Residential) :
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:
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 hereafter, the above nomination should be deemed as cancelled.
2 * Certified that my father/mother is/are dependent upon me.
3. * Strike out whichever is not applicable.

Relationship with
S.No. Name and address of the family members Date of Birth
the member
(1) (2) (3)
(4)
1 Commented [AN4]: Fill the details – If Married –
Spouse/children
2
3
4

---------------------------------------------------------------------- Commented [AN3]: Employee Sign Signature or thumb

impression of the subscriber

Note: - A Fresh nomination shall be made by the member on his marriage and any nomination made before such marriage

Na me and Address of the Nominee Date of Birth Relationship with the member
(1) (2) (3)
Commented [AN5]: For both Married and Unmarried –
Spouse/Children/Other family Mamber(s)

Date : _____________________
Commented [AN6]: Employee Sign and DOJ
shall be deemed to be invalid
# If Married –> Spouse, Children (married or unmarried), his/her dependent parents, deceased son’s widow and children.
If unmarried then Parents, Brother, Sister or any other person(s).
Page No. – 1 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.

** 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 persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii)
of Employees’ Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving

Pension. $$
……………………………………… Signature or
thumb impression of the subscriber

**Strike out whichever is not applicable.

 CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kumari________________________________________________________employed in my 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: _________________

Date: __________________
…………………………………………………………. Signature
of the Employer or other authorized
Officer of the establishment
Designation……………………………………….

Name and address of the Factory/Establishment or

rubber stamp thereof

$ - Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.

$$ - Applicable to both Married and unmarried – (1) Married - To any person(s) other than spouse and children.
(2) Unmarried - To Parents, Brother, Sister or any other person(s).
Instructions: Form has to be submitted on the day of Joining

PAGE NO 1 OF 1

GROUP MEDICAL POLICY AND PROVIDENT FUND DETAILS

PARTICULARS

Date of Birth (dd/mm/yyyy):

Are you a PF member:

Dependent`s details (Only Spouse and Children): Commented [AN10]: Only for Married Employees’

Name :

Staff No: Date of Joining: Age: Level: Blood Grp: Commented [AN7]: Mentioned in Zensar Offer Letter after
Designation (For Ex – F1/E2/G1 etc)

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (Name & Phone No)

Commented [AN8]: Employee DOB

Commented [AN9]: Mention YES/NO only

Sr.No. Name Age Relation Date of Birth Blood Group Gender
(Yrs)

Employee Signature & Date