Fotwt2(ReviseD) va wo? (sia) NOMINATION AND DECLARATION FORM FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS suai al hwo ra sega / eer et Re Declaration and Nomination Form under the Employee's Provident Fund & Employee's Pension Scheme eh fen PRY ge nah er el & oP hae ee PM (Paragraph 33 & 61 (1) of the Employee's Provident Fund Scheme 1952 & Paragraph 18 of the Employee's Pension Scheme 1995) (sor to rer 1052's Ser a9 ae 81 (ted re ers Al 1998-18) 4. Name (in block laters) 7. Address aw (250 stat 8) vat 2. Father's Husband's Name Pormanent ‘ea J ora earth 3. Date of Birth Temporary ve FR arena 8, (A) Date of Joining of EPF Scheme 1952 . oa (s) wa Pt atorn 1552 7 Wea WH RI “ (8) Dato of Joining of EPF Scheme 1971 5. Marital Status (@) @aLh ator s971 A aeear a FARE ‘tate Rete {C) Date of Joining of EP Scheme 1995 (a) eF, ator 1995 Faroe a fer 6. Account No. “ara oat PART-A (EPF) capr-ay (adar®) fear PARE) " heceby nominate the person (s)/ concel the nomination made by me previously and nominate the person (8) ‘mentioned below to receive the amount standing to my credit in the employee's provident fund, in the event of my death. Je BRE A eo harap wee & she aH Ry et oY A eM APY Ake ae) at ee cand sony art afte Pfr ear rer eA eg aha eA Name of Address | Nomince's | Date of| Total amt. or [ithe Nominee is a the felationship | Birth | share of accumu | minor name and relationship nominee! = inthe lation in Provident] & addrose ofthe guardian nominees member | | Fund tobe paid. | who may recalve the FARE | toeach nominee | amount during the aif] wera 8 ore enone dureg the afk sai 1 ‘awa aftr aaer / MON oFominee, wa wen, foes afar | She ger qe ou Suet aifter afinne @y sar fear Stiva a me 7 7. sorter oor | ee Ge ew 41. “Certified that | have no family as defined in para 2 (9) of the Employee's Provident Fund Scher 1952 and Shoulé | acquire a femiy hereater the above nomination should be deemed as cancelled sie Ro ret & Ps enh aon Pes nek A ter = (a) ogee er RE tare lB SF wae cea Ry Rare Bar B A Ove TR CE TERT aT | 2. Certified that my father! mother is/are dependent upon me satis Peat nat BR AR Remar ge we Pa B : *Stike out whichever isnot applicable, Signature oF thumb impression of the subscriber sy 8 8 ey Pheer 8 vee seat ie a at