RISHAB GOLA 100661307

PLEASE FILL THE FORM IN BLOCK LETTERS

JK RK ID : Candidate ID
CANDIDATE INFORMATION FORM

Bank Account Information :

Branch Manager
 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)

1Name :
2Father's
( In Block/ :
3Date
Husband's :
Letters)
4S :
of
Name
5Marit
ex :
Birth
6Accou :
al
7Ad
nt Per :
Status
Numbe Te
dres ma :
sr
8Date mp
nen :
E
of ora
t :
P
Joining ry :
F
E
P
S

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 of the Nominee's relationship Date of Total amount of share of if the nominee is minor name &
Nominee/ Nominees with the member Birth accumalation in provident address & relationship of the
fund to be paid to each nominee guardian who may recive the amount
1 2 3 4 5

Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme 1952 and should I
1
acquire a family hereafter the above nomination should be deemed as cancelled
2
Certified that my father / mother is / are depended 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 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

S.No Name of the Family Members Address Date of Birth Relationship

1
2

3
4
5

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 :
x
Signature / Thumb impression of the subscriber

CE
RT
IFI
CA
TE
BY
E
 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)

1Name ( In Block: Letters)

2Father's / Husband's
: Name
3Date of Birth :
4Sex :
5Marital Status :
6Account Number:
7AddressPermanent:
Temporary:
8Date of Joining :
EPF
:
EPS
:

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 of the Nominee's relationship Date of Total amount of share of if the nominee is minor name &
Nominee/ Nominees with the member Birth accumalation in provident address & relationship of the
fund to be paid to each nominee guardian who may recive the amount
1 2 3 4 5

Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme 1952 and should I
1
acquire a family hereafter the above nomination should be deemed as cancelled
2
Certified that my father / mother is / are depended 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 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

S.No Name of the Family Members Address Date of Birth Relationship

1
2

3
4
5

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 :
x
Signature / Thumb impression of the subscriber

CE
RT
IFI
CA
TE
BY
E
 ?kks"k.kk i=k DECLARATION FORM QkeZ&1@Form-1
?kks"k.kk i=k deZpkjh }kjk Hkjk tk,xkA QkeZ ds LkkFk iksLVdkMZ vkdkj ds nks QksVksxzkQ Hkh yxk, tkus pkfg,A QkeZ Hkjus ls igys
ihB i`"B ij nh xbZ fgnk;rksa dks Hkyh&Hkkafr i<+ ysuk pkfg,A ;g QkeZ fu%9kqYd gSA
To be filled by employee after reading instruction overleaf. Two Postcard Size phtographs to be
attached with the form. This form is free of cost.
¼d½ chekÑr O;fDr ds fooj.k ¼[k½ fu;kstd ds fooj.k
(A) INSURED PERSON’S PARTICULARS (B) EMPLOYER’S PARTICULARS
9-
1- chek la[;k@Insurance fu;kstd dh dwV la[;k
Employer’s Code No.
No.
10- fu;qfDr dh rkjh[k fnu eghuk
2- uke ¼Li"V v{kjks esa½ Date of Appointment Day Month
Name in block letters

3- firk@ifr dk uke 11- fu;kstd dk uke vkSj irk@Name & Address of

Father’s/Husband’s
Name
4- tUe dh frfFk fnu eghuk o"kZ
Date of Birth Da Mont Yea
y h r 12- ;fn igys fu;kstu esa jgs gSa rks Ñi;k fuEufyf[kr C;kSjs
In case of any previous employment please fill
as under.
6- ¼d½ fiNyh chek la[;k
(a) Previous Ins. No.

7- orZeku irk@Present Address 8- LFkk;h irk@ ¼[k½ fu;kstd dwV la[;k

¼d½ e`č;q dh fLFkfr esa udn fgrykHk ds Hkqxrku ds fy, d-jk-ch- vf/kfu;e] 1948 dh /kkjk 71@d-jk-ch- ¼dsUnzh;½ fu;e] 1950 ds fu;e 56¼2½ ds varxZr ukfer ds C;kSjsA
(c) Details of Nominee u/s 71 of ESI Act 1948/Rule-56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the
event of death.

uke@Name ukrsnkjh@Relationship irk@Addres

s

eSa ,rn~}kjk ?kks"k.kk djrk@djrh gwa fd esjs }kjk izLrqr fd, x, fooj.k esjh tkudkjh vkSj fo9okl ds vuqlkj lgh gSA eSa vius ifjokj ds lnL;ksa esa gq, ifjorZu dh lwpuk
15 fnu ds Hkhrj izLrqr djus dk opu Hkh nsrk gwa@nsrh gwaA
I hereby decalare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to
intimate the corporation any changes in the membership of my family within 15 days of such change.

fu;kstd ds izfrgLrk{kj chekÑr O;fDr ds gLrk{kj@vaxwBk fu9kku

Counter signature by the employer Signature /T.I.of IP.

lhy lfgr gLrk{kj

Signature with seal
¼?k½ chekÑr O;fDr ds ifjtuksa dk fooj.k
(D) Family Particulars of Insured person
Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with jgs gSa\ crk,a dk LFkku n9kkZ,a
Date of Birth/Age as the Employee Whether If’ No’ state Place
on residing of
date of filling with Residence
form him/her.
gk¡@Yes ugha@No dLck@Town jkǔ;@Stat
e

d-jk-ch- fuxe vLFkk;h igpku i=k ¼fu;qfDr dh rkjh[k ls 3 eghus rd oS/k½

ESI Corporation Temporary Identity Card (Valid for 3 month from the date of appointment)

uke@Name
chek la[;k@Ins. No. fu;qfDr dh rkjh[k@Date of appointment
9kk[kk dk;kZy; vkS"k/kky; QksVks ds fy, LFkku
Branch Office Dispensary (Space for
photograph)
fu;kstd dh dwV la[;k o irk
Employer’s Code No. & Address

oS/krk
Validity
rkjh[k chekÑr O;fDr ds gLrk{kj@vaxwBs dk fu9kku lhy lfgr 9kk[kk izca/kd ds gLrk{kj
Dated Signature/T.I. of I.P. Signature of B.M. with seal
 vuqns9k
INSTRUCTIONS

1- QkeZ&1 dk izs"k.k d-jk-ch- ¼lk/kkj.k½ fofu;e] 1950 ds fofu;e 11 o 12 ds varxZr fofu;fer fd;k tkrk gSA
Submission of Form-I is governed by regulation 11 & 12 of ESI (General) Regulations, 1950

2- ßdqVqEcÞ ls fdlh chekÑr O;fDr ds fuEufyf[kr lHkh vFkok dksbZ ukrsnkj vfHkizsr gS%&
vFkkZr~%& ¼1½ fookfgrh ¼2½ chekÑr O;fDr ij vkfJr dksbZ /keZt ;k nÙkd vo;Ld vkfJr ckyd] ¼3½ dksbZ ckyd tks chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS rFkk tks ¼d½ f9k{kk izkIr dj jgk gS] muds 21 o"Z dh vk;q izkIr dj ysus rd ¼[k½ dksbZ vfookfgr iq=kh]
¼4½ dksbZ ckyd tks fdlh 9kkjhfjd vFkok ekufld vilkekU;rk ;k pksV ds dkj.k f9kfFkykax gS rFkk f9kfFkykaxrk jgus rd chekÑr O;fDr
ds miktZuksa ij iw.kZr% vkfJr gS] ¼5½ vkfJr ekrk&firk] ¼C;ksjs gsrq d-jk-ch- vf/kfu;e] 1948 dh /kkjk 2 ds [kaM 11 dks ns[ksa½A
“Family” means all or any of the following relatives of an Insured Person namely:-

(i) a spouse (ii) a minor legitimate or adopted child dependant upon the I.P.; (iii) a child who is wholly
dependant on the earnings of the I.P. and who is (a) receiving education, till he or she attains the age of
21 years (b) an unmarried daughter;
(iv) a child who is infirm by reason of any physcial or mental abnormality or injury and is wholly
dependant on the earnings of the I.P. so long as the infirmity continues; (v) dependant parents (Please
see Section 2 clause 11 of the ESI Act 1948 for details.

3 igpku&i=k vgLrkUrj.kh; gSA

Identity Card is Non-Transferable.

4- igpku&i=k ds xqe gksus dh fLFkfr esa fu;kstd@9kk[kk izca/kd dks rčdky lwfpr fd;k tk,A
Loss of Identity Card be reported to Employer/Branch Manager immediately.

5- fdlh izdkj dh xyr lwpuk nsus dh fLFkfr esa d-jk-ch- vf/kfu;e] 1948 dh /kkjk&84 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
Submission of false information attracts penal action Under Section 84 of ESI Act. 1948.

6- ubZ fu;qfDr dh fLFkfr esa Hkyh&Hkkafr Hkjk gqvk ;g QkeZ fu;qfDr ds nl fnu ds Hkhrj lacaf/kr 9kk[kk dk;kZy; esa vo9; gh izLrqr fd;k
tkuk pkfg,A foyEc dh fLFkfr esa fu;kstd ds foy) /kkjk&85 ds rgr dkuwuh dk;Zokgh dh tk ldrh gSA
This form duly filled in must reach the concerned Branch Office within 10 days of appointment of an
Employee. Delay attracts penal action under Section 85 of the Act, against employer.

7- chekÑr O;fDr gksus ds ukrs vki o vkids ifjokj ds vkfJrtu fpfdčlk fgrykHk izkIr dj ldsaxsA vU; udn fgrykHk gSa] ¼1½ chekjh
fgrykHk ¼2½ vLFkk;h viaxrk fgrykHk ¼3½ LFkk;h viaxrk fgrykHk ¼4½ vkfJrtu fgrykHk ¼5½ izlwfr fgrykHk ¼efgyk deZpkjh ds fy,½A
As an insured person you and your dependant family membes are entitled to full medical care. The other
benefits in cash include (1) Sickness Benefit (2) Temporary Disablement benefit (3) Permanent disablement
Benefit (4) Dependants benefit and (5) Maternity Benefit (in case of woman employees) subject of
fulfillment of contributory cnditions.

8- vf/kd tkudkjh ds fy;s Ñi;k fuxe ds osclkbV dks nsa[ksa ;k 9kk[kk dk;kZy; ;k {ks=kh; dk;kZy; ls laidZ djsaA
For more details please contact website of ESIC at www. esic.org. in. or contact Regional Office or Branch
Office.

dsoy 9kk[kk dk;kZy; esa iz;ksx gsrq

For Branch Office Use only
1- chek la[;k vkoaVu dh rkjh[k %
Date of allotment of Ins. No. :
2- vLFkk;h igpku i=k tkjh djus dh rkjh[k %
3- Date of Issue of T.I.C. :
vkS"k/kky; dk uke@la[;k %
Name /No. of Dispensary :
4- D;k vU;ksU; fpfdčlk O;oLFkk miyC/k gS\ ;fn gkaa] rks mYys[k djsa %
Whether reciprocal Medical arrangements involved. if yes, please indicate :
9kk[kk izcU/kd ds gLrk{kj
Signature of Branch Manager

Ø-la- uke QkeZ Hkjus dh rkjh[k deZpkjh ds lkFk ukrsnkjh D;k muds lkFk jg ;fn ugha] rks vkokl
SI. No. Name dks vk;q@tUe&rkjh[k Relationship with jgs gSa\ crk,a dk LFkku n9kkZ,a
Date of Birth/Age as the Employee Whether If’ No, state Place
on residing of
date of filling with Residence
form him/her.
gk¡@Yes ugha@No dLck@Town jkǔ;@Stat
e
 FORM –‘F’
PAYMENT OF GRATUITY ACT.
[ SEE SUB-RULE (1) of Rule 6 ]
NOMINATION
To,
…………………………………………………...
…………………………………………………...

[ I Give here name or description of the establishment with full address ]

1.
Shri/Shrimati………………………………………………………………
……………….
[Name in the here]

Whose particulars are given in the statement below. I hereby nominate the
person(s) mentioned below to receive the gratuity payable after my death as
also the gratuity standing to my credit in the event of my death before the
amount has become payable or having become Payable has not been paid
and direct that the said amount of gratuity shall be paid in proportion
indicated against the name(s) of the nominee(s)

2. I hereby certify the person (s) mentioned is/are a member (s) of my

family within the meaning of clause (h) of Section (2) of the payment of
Gratuity Act. 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of
section (2) of the said Act.

4. (a) My Father/Mother/Parents is/are not dependent on me.

(b) My husband’s/father/mother/parents is/are not dependent on my husband.

5. I have excluded My Husband from my family by a notice dated the ……….

to the controlling authority in terms of the provision to clause (h) of section 2
of the said Act.

6. Nomination made herein invalidates my previous nomination.

NOMINEE’S

Name in full with Relationship Age of Proportion by which

full address of with the nomine the gratuity will be
nominee(s) (1) employee e (3) shared (4)
(2)
 STATEMENT
1. Name of the employee in
full……………………………………………………………………..
2.
Sex……………………………………………………………………
……………………………..
3.
Religion……………………………………………………………………
………………………..
4. Whether
unmarried/married/widow/widower…………………………………………
…………
5. Department Branch/Section where
employed………………………………………………….
6. Post held with Ticket No. Serial No. if
any………………………………………………………
7. Date of
appointment………………………………………………………………
……………….
8. Permanent
address……………………………………………………………………
…………..
Village………………………………Thana……………………Sub
Division……………………
Post
Office………………………….District…………………..State……………
……………….
Place-
Signature/Thumb Impression
Date……………. of the employee

Declaration by witnesses
Nomination signed/Thumb impressed
before me Name in full and full address of
witnesses

signature of witnesses
Place:

Date………………………

Certificate by the employer

Certified that the particulars of the above nomination have been verified and
recorded in this establishment

Employer’s reference No, if any Signature of the employer/Officer

authorized
 Designation

Name address of the establishment

Date……………….. or rubber stamp there of

Acknowledgment by the employee

Received the duplicate of the nomination in Form ‘F’ Filled by me and duly
certified by the employer.

Date……………………

Note: Strike out words/paragraph not applicable Signature of the

employee
 FORM - I
(NOMINATION AND DECLARATION FORM)
[See rule 3]

1 Name of the person making nomination(In block letters):-

2 Father's/ Husband's Name:-

3 Date of Birth:-
4 Gender:-

5 Maritial Status:-

6 Address:-
Permanent:

Temporary:

I herby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned
below to receive any amount due to me from the employer,in the event of my death.
IF THE NOMINEE IS
TOTAL AMOUNT OF
NOMINEE'S MINOR,NAME,RELATIONSHIP
SHARE OF
NAME OF THE RELATIONSHI DATE OF AND ADDRESS OF THE
ADDRESS ACCUMULATIONSIN
NOMINEE/NOMINEES P WITH THE BIRTH GUARDIANWHO MAY RECEIVE
CREDIT TO BE PAID
MEMBER THE AMOUNT DURING THE
TO EACH NOMINEE
MINORITY OF THE NOMINEE

1 2 3 4 5 6

1 Certified that I have no family and should I acquire a family hereafter, the above nomination shall be deemed as cancelled.
2 *Certified that my father/mother is/are dependent upon me.
3 *Strike out whichever is not applicable.

Signature or the thumb impression of the

employed person

CERTIFICATE BY THE EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt/Miss
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.

Signature of the employer or other authorised

officer of the establishment:

Place:-

Date:-
Name and address of the factory/establishment :
 FORM NO. 12B
[See rule 26A]
Form for furnishing details of income under section 192(2) for the year ending 31st March, 20

Name and address of the employee …………………………………………………………………………………………………………………………

EMP ID ………………………………………………………………………………………………………………………………………………..
Permanent Account No. …………………………………………………………………………………………………
Residential Status …………………………………………………………………………………………………

Particulars of salary as defined in section 17, paid

or due to be paid to the employee during the year
Serial Name and address TAN of the Permenen Period of Total amount Total amount Value of Total of Amount Total amount Remarks
Number of employer(s) employer(s) t Account employment of salary of house rent perquisites and columns deducted of tax deducted
as allotted Number exculding allowance, amount of 6, 7 and in respect during the
by the ITO of the amounts conveyance accretion to 8 of life year (enclose
employer(s) required to allowance and employee's insurance certificate
be shown in other allowances provident fund premium, issued under
columns 7 to the extent account provident fund section 203)
and 8 chargeable to (given details contribution,
tax [See section in the Annexure) etc, to which
10(13A) read section 80C
with Rule 2A Applies (Give
and section details)
10(14)
1 2 3 4 5 6 7 8 9 10 11 12

…………………………………….
Signature of the employee

Verification
I,do hereby declare that what is stated above is true to the best of my knowledge and belief.
verified today, the ……………….. day of...............................20

Signature of the employee

 ANNEXURE
[See column 8 of Form No. 12B]
Particulars of value of perquisites and amount of accretion to employee's provident fund account
Name and address of the employee …………………………………………………………………………………………………………………………

Permanent Account No. …………………………………………………………………………………………………

Name of the employee TAN/PAN Value of rent-free accomodation or value of any concession in rent for the accommodation provided by the employer (give basis of computation)
of the [See rule 3(a) and 3(b)]
employer Where accommodation is furnished
Where acco- Value as if Cost of furniture Perquisite value Total of Rent, if any Value of
mmodation accummodation (including Television of furniture (10% columns paid by the perquisite
is unfurnished is unfurnished sets, radio sets, of 4 and 6 employee (column 3
refrigerators, other column 5) OR minus
household appliances actual hire column 8 or
and air-conditioning charges column 7 minus
plant or equipment) payable column 8 as
OR hire charges,if as may be
hired from a third applicable
party

1 2 3 4 5 6 7 8 9
 ANNEXURE
(Contd.)

Whether any conveyance has been Remuneration paid by employer Value of free or Estimated value of any Employer's Interest credited to Total of columns 9 to 15 carried to
for
provided by the employer free or at a domestic and/or personal services concessional other benefit or amenity contribution to the assessee's column 8 of Form No. 12B
concessional rate or whre the employee provided to the employee (give passages on home provided by the recognised providend account in
is employer,
allowed the use of one or more motor details) [See rule 3(g)] leave and other free of cost or at fund in excess of recognised
cars 12%
owned or hired by the employer, travelling to the concessional rate not of the employee's providend fund in
estimated
value of perquisite (give details) [See extent chargable to included in the preceding salary (See Schedule excess of the rate
rule
3 (c )] tax (give details) column (give details), IV- Part A fixed by the Central
[See rule 2B read e.g., supply of Government [See
gas,
with section electricity or water for Schedule IV - Part
10(5)(ii)] house hold consumption, A]
free educational facilities,
transport for family, etc,
(See rule 3(d), 3(e) and
3(f)]

10 11 12 13 14 15 16