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Submit by Email Form is available free of cost FORM -2 REVISED A/C. Group No. NOMINATION AND DECLARATION FORM FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS Declaration and Nomination Form under the employees Provident Funds EPF and Employees Pension Scheme EPS Paragraph 33 61 1 of the Employees Provident Fund Scheme 1952 Paragraph 18 of the Name In Block Letters Date Of Joining in EPF 52 Father s/Husband Name 71/E.P. S* 95 Date Of Birth Sex Permanent Temporary Address Male Female Marital Status Married Account No* 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 Nominee / Address relationship with the member Date of Birth Total amount of share of accumulations in Provident Fund to Be paid to each nominee. If the is a minor Name of the guardian who may receive the amount during the minority of AS PER ABOVE MENTIONED 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* Signature or Thumb impression of the subscriber Strike out whichever is not applicable 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. S r No. Name Address of the Family Member with Date Of Pension Scheme 1995 and should I acquire a family hereafter I shall furnish particulars thereon in the above form* pension admissible under Para 16-2 a i ii in the event of my death without leaving any eligible family member for receiving pension* Name and Address of the Nominee with member CERTIFICATE BY EMPLOYER before me by Shri / Smt. / Kum* employed in my establishment after he/she has read the entries / entries have been read over to him/her by me and got confirmed by him/her. Place Signature of the employer or other authorized Officers of the establishment Designation Rubber Stamp thereof*. S* 95 Date Of Birth Sex Permanent Temporary Address Male Female Marital Status Married Account No* 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 Nominee / Address relationship with the member Date of Birth Total amount of share of accumulations in Provident Fund to Be paid to each nominee. Name of the Nominee / Address relationship with the member Date of Birth Total amount of share of accumulations in Provident Fund to Be paid to each nominee. If the is a minor Name of the guardian who may receive the amount during the minority of AS PER ABOVE MENTIONED 1. If the is a minor Name of the guardian who may receive the amount during the minority of AS PER ABOVE MENTIONED 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* Signature or Thumb impression of the subscriber Strike out whichever is not applicable 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.

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