Employee code

(Mandatory)
FORM 2 (Revised)
(For Unexempted /Exempted Establishmernts)
NOMINATION AND DECLARATION FORM
(Declaration and Nomination Form under the Employees' Provident Funds and Employees Ponsion cheme)
(Paragraphs 33 &61 (1) of the Employeos' Provident Funds Scheme, 1952 and paragraph 18 of the Employsos' Ponsion Schern6, 1995)
1 Name (in Block Letters) :TAN NU KOMART
2 Father's/Husband's Name : SEV KUHAR
3 Date of birth
4 Sex
: 29-08-2005
5 Marital Status
: feMALE
6 Account No. ( s Number)
: UNMARRTED
7 Address (Residential)
:PUPUN O00581+ 00of/0000012517
: Permanent -Aknkiyabur ikrarn Patna Bihar
Temporary - Akhtiyarput Bikrarn Patnai eihar
PART A(EPF) #
Thereby nominate the person(s)/cancel the nomination made by me previously and nominate, the peron(s) rmertioned
below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of rmy death:
Name and Address of the nomineel nominees Nominee's Total amount If the normines s a
Date of
relationship Birth or shars of minor, name and
with the accurmulations relationship and
member in Provident addrsss of the
Fund to be quardian who may
paid to each recetvs the arnount
nominss (%) during the minority of
nominee
(1) (2) (3) (4) (5)
SHTV KUMAR
&
ILPo- AkHTTYARPUR, PS-BTKRAM
DLST-PATNA T NC DE-gO1O4
100%
1 * Certified that I have no family as defined in para 2(g) of the Employees' Provident Funds Scherme, 1952, and
should I acquire a famitly 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.

Signature or thumb impression of the subscriber

IfunmardBd then Parents Excther Sisteror any othet personl5!

[Forra 2 (11
 Part B(EPs) (Para 18) $
Ihereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension
in the event of my death.
SI.No. Name and address of the family members Date of Birth Relationship with
the member

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

4
acquire a
Certified that Ihave no family, as defined in para 2(vi) of Emplovees' Pension Scheme, 1995 and should I
family hereafter Ishall furnish particulars thereon in the above form.
(admissible under para 16 2(a) () and (ü)
Thereby nominate the following persons for receiving the monthly widow pension
any eligible family member for receiving
of Employees' Pension Scheme, 1995 in the event of my death without leaving
Pension. S$$
Date of Birth Relationship with the member
Name and Address of the Nominee

(2) (3)
(1)
12-12- L992 FATHER
STVKUHAR & AkHTTY AR PURL
BTIKRAMPATNA BTHAR

Dated the:
Signature or thumb impression
of the subscriber
applicable.
**Strike out whichever is not
CERTIFICATE BY EMPLOYER
signed/thumb impressed before me by
nomination has been establishment
declaration and employed in my
Certified that the above confirmed by him/her.
Shri/Smt./Kumari him/her by me and got
has read the entries/the entries have been read over to
after he/she
Place:
Dated the other authorised
Signature of the Employer orthe establishment
Officer of
Designation... Factory/Establishment
Name and address of the rubber stamp thereof
or
service
legally before death in
and Chiidren incude children adopted
MartedTo Spouse
S- Appicable if thari spouse and children
Mamed Ta any Dersonis )other any other personis)
and unmaried -{1)
SSApplicable to both Mamied 121Unnaried1ToParents. Brother Sister or

[Fom 2 (1))