Form-2 (REVISED) / un.and-2 (D6 58ugs) NOMINATION AND DECLARATION FORM/ (Suisend op gyi 2 gy S)Qiom uigcuid) UNEXEMPTED/EXEMPTED ESTABLISHMENTS /(ageiwae, Quprs/Quip Dowaniaese) Declaration and Nomination Form Under the Employees’ Provident Funds & Employees’ Pension Scheme BGuuwend op od 2 oP OonPa ugar Agr.o..mu.8. wd yd Og1.9.8.L SHG Ug) Paragraph 33 & 6 (11) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’ Pension ‘Scheme, 1995) Opn peoreni eugtvene eeu HBO. i 1952 un9n 33.8 61 (1)er UUs, Qga.g CL. 1995 LngH 18¢i Ligusd. 1. Name (in Block Letters) Quut (pessoal cups gesafer : 2. Father’s/Husband’s Name Siong/aemoui Quit - 3. Date of BithiSnss God 5 4. Sex feb / Male ayer / Female Quain 5. Marital Status AGuwomoncnause! Hereooun 6. Account No. semis erin. TN 7. Address waft Permanent (615560) Temporary Bhaneds, er 2 8. Date of Joining EPF/ 0.00.88) EPS / gi dw Pw Coids Coo e [ { T PART A (EPF) Atay - «34 (Ogsn.as.8) ' 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 fee Dpiyay Geéronned arcn somade a cron messy HP Ogrmaeurs Gps &pdangpd suiseor HuHsepen. (gren ohaenCa pores Aer OsHoss Huvngong 15g) GeisdGnen) Name & Address of the nominee/ | Nominee's Relationship] Date of | Total amount or share of | ithe Nominee is a Nominees with the member | Birth | accumulations in minor name and Provident Fund to be paid | relationship & address] Dusen’ Quppeut! [Suwa Guppereaeia| spss | —toeach nominee | of the guardian who Gubpeitacter Quuk(acr) epiieiesigs | Sof may receive the = pach sre a pape Qer6% Osrere (Hr Apo gi_Pud QupP. ad GOSUEPH a fw sui PHers ucessler Epargue suer gig Sud Gup Huwond abASpen. (uet 16 (2) (Q) () & (i) 6 uy) Name & Address of the nominee Date of Birth Relationship with the Member Duvend Guppatér Quugs wacky pbs G58) eptlengLen ep bmp Only one nominee should be entered above. Nate: Nominate other than spouselchildren to receive the pension: Incase of unmarried member he/she may nominate any cne of his parents Date see: "Strike out whichever Is not applicable ‘Signature or left thumb impression of the subscriber. Camausnms £40Gs, epideriaatin mauris! ugedee Crea, CERTIFICATE BY EMPLOYER (S)giaser e Renwumanflen encsy) Corti that the above declaration and nomination has been signedithumb impressed before me by shi/smuKum, 1». @mployed in my establishment after he/she read the entries/entries have been read over to himiher by me and got confirmed by him/her. norg Dpmpse velufud 85/008 /Qasrd, . aosiac SBosriiac sp | ncrentes' eral apiut. Od, Ser ygernd Queger YAbg Capargud e HPAP wppd HuwergHO msQuncuid | eaten ocr (inente BX. Girend aénusis Bee scopy. Signature of the employer or authorised officers of the establishment Powe eReourmialPqamsien aGarnd Quapefan mauris Place Name aL Quue Dated the Designation sp use Name & Address of the factory/Establishment or Rubber Stamp thereon Apress Pen | Dpampier Qungd, paahyd ging PEPernyo