wns es ud 9 Ho wetted arfereg fait cite Employees’ Provident Fund Organisation oh adress sia Gaesaes stad pater elaine Tl /Nomination and declaration Form Qecte BACHE | Qoncte weonsts Rosen « ae ‘(Boa ) Ginigonrernt eee ser {aeatin) For Unexempted/ Exempted Establismant, Form’ (Revised) SUS 13H, AO EON, Heecd bout ctecestahO Panel ase Need sce ‘tert fee tre wafer) er ator Sera een Ge TTT Decataron and Nomination Form under the Employees Provident Fund & Einployees’ Pension Scheme (ee a a case 190 Sond she) ase oud cars, 19S E0081) ea FAR alae, 1952 033 wo (1) dane Beate 1995 13 (Paragraph 33.1 (1) of ne Employees’ Provident Fund Scheme, 1952 & Paragraph 19 of sie Employees Pension Senome. 1995) 1, axtcoGT/Name 1. and Kooy, / Pere 2, Sodabinows axons) aia eam ‘Account No: KN/. md, Father's/Husband's Name. 8. eet /at/ Address: 3. wa gpon/aa fe /Date of Bh: ‘szobortnf/ Permanent: “s Saufises gate Male/ ext Female 5. Rignbemysina aes Tey/Mantal status soryos/ stem / Temporary: ‘wart © (99.9.8)/ mt ~ w (water fred fit) / Part - A (EPF) Si HO.NO anSaNO wee Sspiny oH lM aes eda eo See Soa ASE ‘Srtooes eas acrena Hay ot degocsosy mas Dar ebscngss, ‘Reo Boa ton ibe eh rete es EY one (al me f/f Gon ae wh cc md GR en a (at) A aa aT {hereby nominate the person (6V/cancel the nomination made by me previously and nominate ihe person(s) mentioned below to receive the amount standing to my crit inthe Employees Provident Fund, inthe event of my death a eon) hace awe in aa | ONT e |ent delle, Ue, Hepat Abd ral 3 * aelies Bee Sos ues eeetee peat ee qiike: shad 058) ip geo ses ap iF ie see gee | yj E8 PEE) Wg al RT Gi, BO SSCS, USTS WOE (S) SSROT GaN Winge WORIRR SI SSST NSS AE Serena omyoasiom ssncteonennt ee a sr fea are a nr fa fay ate 1952 &% er 2( sh) & agar ard ears aha Herta wa we Sa [Sea TTS * Certified that | have no family as defined in para 1(a) of the Employees’ Provident Fund Scheme, 1952 and should | ‘acquire @ family hereaer the above nomination should be deemed as cancelled. | Sil yoo/encneouen ig ertesous come aaactesorennd fea aa tear gaat Corti that my FathMotier ilar dependent upon me. exsompnbery saci mt sy een at YA TOO aa a fa ecate eae re a FETE aT SBT BE Stce ou whichever is nt applicable Signature or thumb impression othe Subscriber ‘Were wratera sat fey FOR OFFICE USE a fle sft at fe en ata sat aaah A wt ea fate i /A. Ras.aN—2 (B.g.ch60 TF (FAA)/- Part -B (EPS) one (aoad 18) &0-18) (Para-t8) i Scot ew eg maatiecrosagmuentaone htvdsoantt | Sites fon fe or er ga oie ceed eet Bes ee Unerey frie below pacts ofS eters omy tai who weld e ge tev Widow/Chikren Pion nos aerate ‘BibonT RRL ay Owe ea ome | ay Gacbhew zene fear eae esx a Adress safe. |. ada ‘Name of th family member_' Date ot Biah [Relationship with member | : | + RBOo Lowes slaens, 19550 8008 2 (Vi)Og ese pcdsIos aN MU AdaIBY aay ino RSHag md © et206 SH shtgjod sesetohO aectde. | sera fea $c tr ser feos 217) Aes ef, ssstea sre | terete sega a Pa Cert nat Nave ne amy 2s deine in para 2 (ofthe Employees Pension Scheme, 1998 and shoul | ogi a ami heres hal tumian parts thereon nthe above or | Bi Btuedoegaig oiten sonst na, nese Bouts (4004 16(2)(0)() sy (Io By moO waraa) “zetaDED eh sescanom som Arad, +c ear Ea ih ah aa tay cen we Fs reas rh bg ear fe * thereby norrinate the following person for receiving the monthly widow pension (admissible under para 16(2) (a) (ane (i) the event of my- death without leaving any eligible family member for recelving pension. Tae ne -eaee aec ea Oee Romer ER ESSE OSES sifea ara aa a fe aerate Name ix Address of Nominee Date of Birth Relationship with member cmon Reie/Date a _ Roop sad mt Os b eien ates ross hah amy ae se are Teen Ty ier H FeReR TITS OT ‘Strike out whichever is not applicable ‘Signature or thump impression of the subscriber senOxtd a zines ws, /Redtnee ENT STAT H/Cortificate by Employer een goes maria mas Ades Be Beads. i OOD HA Soe 0 Ady /abehayS ToC Tatton. wesc anh nodehe deaberhacdOoeep. EHO Te goN SHUnIvAY LO WH aeveNcFOD 1 sHACE Zaartkeoneane. or sa aren, auth hon ary a ee eT ge o/s a Affe sa nearest Certified that abova declaration, and nomination has béen signedthurnb impressed before me, by SriSmtKum, arg ae aed wa Te, BET AST SHIT GRATE employed in my establishment after‘he/she has fead the entries/have been read over to him/her by me and got confirmed Ly hirher. omoe/feaie /Date cmon nga maseeranse ‘Signature of the employer or other authorised se WEA /Designation Aga marion exe sony tan ‘eth are aH m/e Name & Address of the Factory Establishment Rubber Stamp thereot