Dat

eofAppoi
ntment_
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__

FORM 2
(REVI
SED)

(
P.F.Deduct
iondat
e):
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__

Gr
oupNo.:
Off
ice:
NOMINATION&DECLARATI ONFORM
FORUNEXEMPTED/EXEMPTEDESTABLI SHMENTS
Decl
arat
ionandNominati
onForm undertheEmpl oyees’Pr
ovi
dentFunds
AndEmployees’Pensi
onScheme
(
Par
agraph33&61( 1)oft
heEmpl oyees’Pr
ovidentFundsScheme,1952and
Par
a18oftheEmploy ees’
PensionScheme, 1995)

1.Name(
inbl
ockl
ett
ers)
: _
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AMANSHARMA_
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_

2.FATHER’
S/HUSBAND’
SNAME: _
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YOGESHSHARMA_
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__

3.DATEOFBI
RTH: _
_22/
09/
1998_
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__(
DD/
MM/
YYYY)

4.SEX:_
___
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__Mal
e__
___
__(
Mal
e/Femal
e)

5.MARI
TALSTATUS:
___
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___
__Unmar
ri
ed_
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___
___
___
___
___
___
_(mar
ri
ed/unmar
ri
ed/wi
dow/wi
dower
)

6.P.
F.ACCOUNTNO.
:__
___
_NA_
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___

7.ADDRESS:____
____89,v
ishnucol
ony,
Shahganj,
Agra
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_____
__ _
_____
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_____
_____
____
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_

_
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PART–A(
EPF)

Iher
ebynominat
etheper
son(s)/cancel
thenomi
nati
onmadebymepr ev
iousl
ynomi
natet
heper son(
s),
menti
oned
bel
owtorecei
vetheamountstandi
ngtomycredi
tint
heEmpl
oyees’
Provi
dentFundi
ntheeventofmydeath.

Name&Addr
essoft
he Nomi
nee’
srel
ati
onshi
p Dat
eofBi
rt
h Total
amtorshareof Ift
henomi neeismi nor
,
Nomi
nee(
s) wi
tht
hemember accumul
ati
oninPFtobe name&r el
ati
onship&
paidt
oeachnominee add.Oftheguardianwho
mayr eceiv
etheamount
duri
ngmi nori
tyof
nominee

(
1) (
2) (
3) (
4) (
5)

YogeshShar
ma Fat
her 28/
06/
1971 100% Na

89,vi
shnucol
ony
,
Shahganj
,Agr
a.
1.*Cert
if
iedthatIhavenofamilyasdef i
nedinpara2(g)oftheEmployees’
Provi
dent
FundsScheme, 1952andshouldIacquireaf ami
lyther
eaft
ertheabovenominat
ion
shoul
dbedeemedascancel l
ed.
2.*Cert
if
iedthatmyf at
her/mot heri
s/ar edependentuponme.
(*) strikeoutwhicheveri
snotapplicable

SI
GNATUREORTHUMBI
MPRESSI
ONOFTHESUBSRI
BER

PART–B(
EPS)

Par
a18

Iherebyfur
nishbel
owpar
ti
cul
arsoft
hemember
sofmyf
ami
l
ywhowoul
dbeel
i
gibl
etor
ecei
vewi
dow/chi
l
drenPensi
on
i
nt heeventofmydeat
h.

Sr
.No. Name&Addr
essoft
hef
ami
l
ymember/s Dat
eofBi
rt
h Rel
ati
onshi
pwi
thMember
(
1) (
2) (
3) (
4)
1. Rohi
tShar
ma&89,
vishnucol
ony
,Shahganj
, 19/
05/
1997 Br
other
Agra

)-
()-
( Cer
ti
fi
edthatIhavenofamil
y,asdefi
nedi
nPara2(Vi
i
)oftheEmpl
oyees’
Pensi
onScheme,
1995andshoul
dI
acqui
reaf
amil
yIshallf
urni
shpart
icul
arsther
eonint
heabovef
orm.

Iherebynominat
ethef
oll
owingpersonforreceiv
ingthemont
hlyf
ami
l
ypension(admissi
bleunderPar
a16(
2)(
i)and(
ii
)
i
nt heeventofmydeat
hwithoutl
eavinganyeligi
blef
amil
ymember/sforr
eceiv
ingpensi
on.

Name&Addr
essof Addr
ess Dat
eofBi
rt
h Rel
ati
onshi
pwi
thMember
t
heNomi
nee

(1)RohitShar
ma&89, (2)
89,v
ishnucol
ony
,Shahganj
, (
3)19/
05/
1997 (
4)Br
other
vishnucolony
, Agra
Shahganj,Agra

Dat
e:_
___
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___
24/
04/
2021_
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___

SI
GNATUREORTHUMBI MPRESSIONOFTHESUBSRI
BER
()
-()Str
ikeoutwhi
chev
eri
snotappli
cabl
e

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_

CERTI
FICATEBYEMPLOYER

CERTIFI
EDt hattheabovedeclar
ati
onandnomi nat
ionhasbeensigned/thumbimpressedbefor
emeby: Shr
i/Smt./
Kum.____
_______
_ _
____
____
______
_____
______
___
____
Employedinmy/ourest abli
shmentafterhe/shehasreadtheenti
re/entri
eshav
ebeenr eadovert
ohi
m /herbymeand
gotconfi
rmedbyhi m /her
.
 Pl
ace:
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_ _
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____
Si
gnat
ureoft
heEmployer’
sORother
Dat
e:_
_24/
04/
2021_
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__

Aut
hor
izedOff
icer
’softheEst
abli
shment
Si
gnat
urewithdesi
gnati
on

(
nameandaddr
essoft
hef
act
ory/est
t.orr
ubberst
amp
t
hereof
)