Enter Fathers/Husbands Name

The Employees' Provident Fund Organization

Nomination And Declaration Form

rm No. 2 (Revised)
Place where employee is currently residing

For Unexampled/Exempted Establishments

Declaration and Nomination Form under the Employees' Provident Fund and Employees' Pension Scheme (Paragraph 33 and 61 of the Employees' Provident Scheme, 1952 & Paragraph 18 of the Employees' Pension Scheme)
Employee Name Employees Ignore

01. Name (in block letters) __Mukesh Bhatia____________ ________________________________________________ 2. Fathers/Husband's Name ___Rajat Bhatia__________ (In case of married woman)_______________________ 03. Date of Birth ________05/09/1977____ 04. Sex Male Male
dd /mm /yyyy

6. Account No. KN/BN/__________________ 7. Temporary Address: No 480 2nd Cross

prestige Apartments West of the chord Road Rajajinagar, Bangalore-560036

Permanent Address: No 240 6th Cross

prestige Apartments West Mambalam

1. Female
Married/Unmarried

05. Marital Status _____Married________________________

Date of Birth of each Nominee PART-A (EPF)

Chennai-560033 Place of permanent residence

I here by nominate the person(s)/cancel the nomination made by me previously and nominate the persons(s), mentioned below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death:
Name and Address of the nominee/nominees Nominees relationship with the member Date of Birth Total amount or share of accumulations in Provident Fund to be paid to each nominee (%) If the nominee is a minor, name and relationship and address of the guardian who may receive the amount during the minority of nominee

Name And address of each Nominee

(1)
Sheela Bhatia Relationship With each Nominee Share of each Nominee in Percentage

(2)
Wife Father

(3)
05/04/1985 07/06/1950

(4)
40% 20%

(5)

Rajat Bhatia

01.* 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. 02* Certified that my father/mother is/are dependent on me. X *Strike out whichever is not applicable Employee Signature

Signature or thumb impression of the subscriber FOR OFFICE USE ONLY Employees Ignore

Name and address of Family Members

Part B ( EPS) Para 18 (EPF)

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. Date of Birth of each Member
Sl. No. Name and address of the family members Date of Birth Relationship with the member

(1) 1 2

(2)
Sheela Bhatia Rajat Bhatia

(3)
05/04/1985 07/06/1950

(4)
Wife Father

Relationship With each Member

** Certified that I have no family, as defined in Para 2(vii) of Employees Pension Scheme, 1995 and should I acquire a family hereafter I shall furnish particulars thereon in the above form. I here by nominate the following persons for receiving the monthly widow pension (admissible under Para 16 2(a) (i) and (ii) of Employees Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving Pension.
Name and Address of the Nominee Date of Birth Relationship with the member

Name and address of Family Members

(1)
Sheela Bhatia Rajat Bhatia

(2)
05/04/1985 07/06/1950

(3)
Wife Father Relationship With each Member

Date of Birth of each Member

Date: 13/08/2012
X

Employees Signature

*Strike out whichever is not applicable

Enter date as on when form is signed by employee

Signature or thumb impression of the subscriber

Employees Ignore

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Kumari__________________________________________________________________________ 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 authorized officer of the establishment

\ Date:____________

Name and address of the Factory/Establishment or rubber stamp thereof