FORM - 2 (REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Fund and Employees Pension Scheme.
(Paragraph 33 & 61(1) of the Employees Provident Fund Scheme, 1952 & Paragraph 18 of the Employees Pension Scheme, 1995)

1. Name in CAPITALS:…………………………………………………………………………………………

2. Fathers’ Name :……………………………………………………………………………………………….

3. Date of Birth: ……………………………………… 4. Male/Female ……………………………………

5. Marital Status: ……………………………………… 6. PF Account Number: MH/KND/211605/……… Leave it Blank

7. Address : Permanent:…………………………………………………………………………………………..
……………………………………………………………………………………………
Temporary…………………………………………………………………………………………..
……………………………………………………………………………………………

Leave it Blank
8. Date of joining E.P.Scheme,1995:………………………………………………………………………….

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.

Name of the Address of the Nominee’s Date of Birth Total Amount of If the Nominee
Nominee/ Nominees Relationship share of is minor, name,
nominees with the member accumulations in relationship and
Provident Fund to address of the
be paid to each guardian who
nominee. may receive the
amount during
the minority of
nominee
(1) (2) (3) (4) (5) (6)

Fill the details of Nominee for PF Amount

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.

Sign Here
Signature of the subscriber/member
 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.

Serial Name of the family Address of the family member Date of Birth Relationship with
Number member the member

(1) (2) (3) (4) (5)

Fill the details of Son/Daughter and

spouse (Husband/Wife) if you are Married
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 widow pension (admissible under Para 16
(2)(a)(i) and (ii) of the Employees Pension Scheme, 1995 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 the member

Fill the details of Father/Mother/Brother,

if you are Unmarried
Sign Here
Date:

Signature of the member/subscriber

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 have been
read over to him/her by me and got confirmed by him/her.

Date: for CORPSOLUTIONS SERVICES PVT. LTD.

Authorised Signatory

CORPSOLUTIONS SERVICES PVT. LTD.

235, Blue Rose Industrial Estate, Near Cable
Corporation, Western Express Highway,
Borivali (E), Mumbai – 400066.
Note: WHOM YOU CAN NOMINATE

(A) UNDER THE EMPLOYEES' PROVIDENT FUND SCHEME

A member of Employees' Provident Fund who is married and / or his father/ mother is/are dependent upon him
can nominate only one or more persons belonging to his family as defined below:

In the case of a male member his wife, his children, his dependent parents and his deceased son's widow and
children;

In the case of a female member; her husband, her children, her dependent parents, her husband's dependent
parents, her deceased son's widow and children.

If the member has got no family, or is a bachelor; nomination may be in favour of any person or persons, whether
related to him or not or even to an institution. If the member subsequently acquires a family, such nomination
shall forthwith become invalid by default and the member should make a fresh nomination in favour of one or
more persons belonging to his family.

(B) UNDER THE EMPLOYEES PENSION SCHEME:

Under Employees Pension Scheme, 1995, Family has been defined as –

Family means –
i) wife in the case of a male member of the Employees Pension Fund
ii) husband in the case of a female member of the Employees Pension Fund; and
iii) sons and unmarried daughters.

Explanation: The expression "sons" and "daughters" shall include children adopted legally before death in
service.
A member who is not married or who does not have any living spouse and/or an eligible child may nominate a
person to receive benefits as laid down in the Employees’ Pension Scheme, 1995, provided that in the event of
his/her acquiring a family subsequently, the nomination so made shall become void. In the event of death of the
member such a nominee shall be entitled to receive a monthly pension equal to the monthly widow’s pension, as
admissible under Employees Pension Scheme, 1995.

If a member dies leaving behind no spouse and/or an eligible child falling within the definition of family and no
nomination by such deceased member exists, the widow pension shall be paid to dependent father or dependent
mother, as the case may be. On grant of Pension to such dependent father and in the event of death of the father
pensioner, the admissible pension shall be extended to the surviving mother for life long.

(C) UNDER THE EMPLOYEES DEPOSIT LINKED INSURANCE SCHEME, 1976.

Nomination made by an employee under Provident Fund is treated as nominations under the EDLI Scheme, 1976
and assurance amount shall become payable to such nominee or nominees.

If no mination subsists or if the nomination relates only to part of the amount standing to his credit in the Fund,
the whole amount or the part thereof to which the nomination does not relate, as the case may be, shall become
payable to the members of his family in equal shares; provided that no share shall be payable to –

a) Sons who have attained majority;

b) Sons of a deceased son who have attained majority;
c) Married daughters whose husbands are alive;
d) Married daughters of a deceased son, whose husbands are alive
e) If there is any member of the family other than those specified in Caluse (a), (b),(c) and (d) above.