The Employees' Pension Scheme, 1995

FORM 2
EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
[Paragraphs 33 AND 61(1)]
EMPLOYEES' PENSION SCHEME, 1995
[Paragraphs 18]

DECLARATION AND NOMINATION FORM UNDER THE EMPLOYEES' PROVIDENT FUNDS

SCHEME AND EMPLOYEES' PENSION SCHEME

1. UAN : 100600477644
2. Name (in block letters) : SURENDER KUMAR
3. Father's / Husband's Name : SATISH KUMAR
4. Date of Birth : 02/12/1992
5. Gender : MALE
6. Marital Status : MARRIED

7. Address (Permanent) : H No 197, VPO Atterna, Sonipat, SONIPAT, HARYANA, 131023

8. Address (Temporary) : H No 197, VPO Atterna, Sonipat, SONIPAT, HARYANA, 131023

9. (A) Date of Joining of EPF : 01/05/2015

(B) Date of Joining of FPS : --
(C) Date of Joining of EPS : 01/05/2015

PART A (EPF)
I hereby nominate 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

If the Nominee is
Total amount or
minor, name and
share of
Nominees's relationship and
Name of the accumulations in
relationship with Date of Birth address of the
Nominee / Nominees Address Provident Fund to
the Member guardian who may
be paid to each
receive the amont
nominee
during the minority of

(1) (2) (3) (4) (5) (6)

H No 197, VPO Wife 22/07/1993 100% --

Atterna, Sonipat,
MANISHA CHAUHAN
SONIPAT, HARYANA,
AADHAAR: XXXX
131023
XXXX 6085
Bank A/c: NOT
AVAILABLE

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

2. *Certified that my father/mother is/are dependant upon me.

(Signature is not required as the document is to be digitally signed)

 The Employees' Pension Scheme, 1995

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:

Sl. No. Name of the Family members Relationship with

Address Date of Birth
the
(1) (2) (3) (4) (5)

1 H No 197, VPO Atterna, 22/07/1993 Wife

MANISHA CHAUHAN Sonipat, SONIPAT, HARYANA,
AADHAAR: XXXX XXXX 6085 131023
Bank A/c: NOT AVAILABLE

*Certified that I have no family as defined in Para 2(vii) of the Employees' Pension
Scheme, 1995 and should I acquire a family hereafter I shall furnish particulars thereon in

I hereby nominate the following person for receiving the monthly widow pension
admissible under para 16(2)(a)(i) and (ii) in the event of my death without leaving any

Relationship with the member

Name and Address of the Nominee Date of Birth

-- -- --

Date 18-Mar-2025

(Signature is not required as the document is to be digitally signed)