The Employees’ Pension Scheme, FORM 2 [Paragraphs 18] EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 [Paragraphs 33 AND 61(1)] EMPLOYEES’ PENSION SCHEME, 1995 DECLARATION AND NOMINATION FORM UNDER THE EMPLOYEES’ PROVIDENT FUNDS ‘SCHEME AND EMPLOYEES’ PENSION SCHEME 4. UAN 101383428540 2. Name jn bioek letters) YOGESH RAVINDRA TELURE 3, Father's / Husband's Name : RAVINDRA 4, Date of Birth = 1170/1894 5, Gender MALE 6. Marital Status UN-MARRIED 7. Address (Permanent) A2 1102 SHRI SHRAM SAFLYA CHS, OPP BARA BUNGLOW KOFRI, THANE, THANE, MAHARASHTRA, 400603 8. Address (Temporary) THANE, THANE, MAHARASHTRA, 400603 9. (A) Date of Joining of EPF Scheme, —: 01/09/2018 (B) Date of Joining of FPS Scheme, (C) Date of Joining of EPS Scheme, 01/09/2018 PART A (EPF) :A2 1102 SHRI SHRAM SAFLYA CHS, OPP BARA BUNGLOW KOPRI hereby nominate person(s) J cancel the nomination made by me previously and nominate the person (5) mentioned below to receive the amount standing to my credit in the Employees’ Provident Fund, in the the Nominee is SUNDA RVIANOR | BEHIND PANYACHYA PrinkitHAN THANE, AnpanAan.200% Iino oceos once NOT RIMABLE Total amount or | minor, name and Nominees's share of relationship and Name ofthe relationship ith accumuations in | address ofthe Honihes steer onss| hakom the Member | P#®°"5I" | Provident Fund to | guardian who may bepaidtoeach | receive the amont nominee | during the minonty of nominee: o @ @ a) © © BE. BLUDNO 150PP Dependent 2orranses 100% a KOPRI COLONY , Mother 1. *Cortfied that | have no family as defined in Para 2(g) of the Employees’ Provident Funds Scheme, 1952 and should | acquice 2 family hereafter the above nomination should be deemed as cancelled, 2. “Certified that my fatherimother is/are dependant upon me. (Signature is not required as the document is tobe igitally signed)