FORM - 2

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NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Fund and Employees Pension
Scheme (Rule 25 of the Tata Consultancy Services Employees Provident Fund Rules & Paragraph
18 of the Employees Pension Scheme, 1995)

1. Name (In Block Letters): XXXXXXXX Employee’s personal details

2. Father’s /Husband’s Name: XXXXXXXX
3. Date of Birth: 17/06/1973
4. Male/Female: Female
5. Marital Status: Single Your TCS Employee Number should be
6. PF Account Number: MH/BAN/48475/XXXXXXX mentioned here after a prefix –
MH/BAN/48475
7. Address:
a. Permanent: Xxxxxxxx Xxxxxxxxxxx Xxxxxxx, Tamil Nadu 600 044
b. Temporary: : Xxxxxxxx Xxxxxxxxxxx Xxxxxxx, Tamil Nadu 600 044
8. (a) Date of joining EPF Scheme, 1952: dd/mm/yyyy Date of Joining Provident Fund Scheme and date
(b) Date of joining E.P. Scheme, 1995: dd/mm/yyyy of joining Employee’s Pension Scheme: You may
write your TCS Date of joining here.
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If you are unmarried, you can nominate your parents. If PART – A (EPF)
your parents are deceased, you may nominate any
person including your brother / sister / any other
I hereby Nominate the person(s)/ cancel the nomination made by me previously and nominate
person. When you acquire a family in future, you are
the person(s)
required to submit mentioned below to receive the amount standing to my credit in the Employees
a fresh nomination.
Provident Fund, in the event of my Death.
Total Amount If the Nominee is
of share of minor, name,
Nominee’s
Name of the accumulations relationship and
Address of the Relationship Date of
nominee/ in Provident address of the guardian
Nominees with the Birth
nominees Fund to be who may receive the
member
paid to each amount during the
nominee minority of nominee
XXXXX XXXX
Mr. XXXXX
XXXXX XXXX – 600044 Father 18-Jun-1940 100
XXXXXXX
Tamil Nadu, India

 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.
Select  2. Certified that my father/ mother is/ are dependent upon me.
appropriately
as applicable. Sign here

Signature of the subscriber/member

 PART – B (EPS)
(Para 18)
Name of the Family Address of the Relationship with
Serial No. Date of Birth
member Family Member the member

Certified that I have no family, as defined in Para 2 (vii) of Employee Pension Scheme, 1995 and
should I acquire a family hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible)
underfillPara
If you are unmarried, your 16 (2)(a)(i) and (ii) of the Employees Pension Scheme, 1995 in the event of my death
nominee details in the second
without leaving any eligible family member or receiving pension.
table of Part B (EPS), leave the
first table blank.
Name of the Relationship with the
Address of the nominee Date of Birth
nominee member
XXXXX XXXX
Mr. XXXXXX XXXXXX XXXXX XXXX – 600044 18-Jun-1940 Father
Tamil Nadu, India

Sign here

Date: dd/mm/yyyy Signature of the subscriber/member

CERTIFICATE BY THE EMPLOYER

Certified that the above declaration and nomination has been signed before me by
Shri/Smt./Kumari______________ in my establishment after he/she has read the entries have
been read over to him/her by me and got confirmed by him/her.

Date: Signature of the employer or

Other authorized Officer of the establishment