NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENT

(FORM 2A (REVISED))

Declaration and nomination Form under the Employee Provident Funds & Employee Pension scheme9 Paragraph 33& 66 91) of the employee Provident fund Scheme , 1952 & paragraph 18 of the Employees Pension scheme , 1995

1. Name.

7. Account no

2. father/Husband Name..

8. Address.

3. Date of Birth..

9. Permanent .. . .

4. Sex 5. Marital Status .. 10. Temporary. . 6. Date Of Joining .

PART -A (EPF) I hereby nominatebthe person (s) cancel the nomination made by me previously and nominate the person (s) mentioned below to recive the amount standing to my credit in the Employee s Provident Fund in the event of death.

Name of Nominee

Address

Relationship

Date of Birth

Total Share

If the nominee is minor the guardian who may recive the 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 here after the above nomination should be deemed or cancelled. 2. certified that my father /mother is /are dependent upon me. signature or thumb imperession of the Subscriber

PART -B (EPS) (PARA 18) I HEREBY FURNISH BELOW PARTICULAR OF THE MEMBERS OF MY family who would be eligibel to recive widow/children pension in the event of my death. Sr. No. 1 Name Address Of the Family 2 Address 3 Date of birth 4 Relation ship with member 5

Certified that I have no family as defined in para (2V11)of Employees Pension scheme1995 and should I acquire a family hereafter I shall furnish particular there on the above form. I hereby nominate the following person for reciving the monthly widowpension (admissible under para 16(2) a(1) 7 11 in the event without leaving any eligible member for reciving pension. Name Address Of the Nominee Date of birth Relation ship with member

Date .. Strike out Whichever is not applicable

signature or thumb imperession of the Subscriber

CERTIFIED BY EMPLOYER Certified that the above declaration and nominatio has been signed / thumb impresseed before me by Shri/smt/ KumEmployed in my establishment after he/she has read the entires have been read over to him /her by me and got confirmed by him/her. signature of the employer of other autorised officers of the establishment. Designatio Name and address of the factory/establishment Place .. or rubber stump therof. Date..