The Employees' Pension Scheme,

FORM 2
EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
[Paragraphs 33 AND 61(1)]
EMPLOYEES' PENSION SCHEME, 1995
[Paragraphs 18]

DECLARATION AND NOMINATION FORM UNDER THE EMPLOYEES' PROVIDENT FUNDS

SCHEME AND EMPLOYEES' PENSION SCHEME

1. UAN : 100123485578
2. Name (in block letters) : CHANDRAMA YADAV
3. Father's / Husband's Name : R M YADAV
4. Date of Birth : 01/08/1970
5. Gender : MALE
6. Marital Status : MARRIED

7. Address (Permanent) : SAREYA WARD NUMBER 13, GOPALGANJ, GOPALGANJ, GOPALGANJ,

BIHAR, 841428
8. Address (Temporary) : SHIV PURAM COLONY , SISAI WARD NUMBER 3, KICHHA, UDHAM
SINGH NAGAR, UTTARAKHAND, 263148
9. (A) Date of Joining of EPF Scheme, : 01/03/2010
(B) Date of Joining of FPS Scheme, : --
(C) Date of Joining of EPS Scheme, : 01/03/2010

PART A (EPF)
I hereby nominate 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

If the Nominee is
Total amount or minor, name and
Nominees's share of relationship and
Name of the
relationship with accumulations in address of the
Nominee / Nominees Address Date of Birth
the Member Provident Fund to guardian who may
be paid to each receive the amont
nominee during the minority of
nominee
(1) (2) (3) (4) (5) (6)

SHIV PURAM COLONY, Wife 14/03/1975 50% --

SISAI WARD NUMBER
MALA DEVI
3, KICHHA, UDHAM
AADHAAR: XXXX
SINGH NAGAR,
XXXX 4223
UTTARAKHAND,
Bank A/c:
263148
692200170000XXX
X
IFSC:
PUNB0692200
 If the Nominee is
Total amount or minor, name and
Nominees's share of relationship and
Name of the
relationship with accumulations in address of the
Nominee / Nominees Address Date of Birth
the Member Provident Fund to guardian who may
be paid to each receive the amont
nominee during the minority of
nominee
(1) (2) (3) (4) (5) (6)

SHIV PURAM COLONY, Daughter 24/06/2004 25% CHANDRAMA

SISAI WARD NUMBER YADAV
KIRAN YADAV
3, KICHHA, UDHAM FATHER
AADHAAR: XXXX
SINGH NAGAR, SHIV PURAM
XXXX 7095
UTTARAKHAND, COLONY SISAI
Bank A/c:
263148 WARD NUMBER 3
692200150001XXX
KICHHA
X
IFSC:
PUNB0692200

SHIV PURAM COLONY, Daughter 22/05/1999 25% --

SISAI WARD NUMBER
SHOBHA YADAV
3, KICHHA, UDHAM
AADHAAR: XXXX
SINGH NAGAR,
XXXX 5259
UTTARAKHAND,
Bank A/c:
263148
692200150000XXX
X
IFSC:
PUNB0692200

1. *Certified that I have no family as defined in Para 2(g) of the Employees' Provident Funds Scheme, 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled.

2. *Certified that my father/mother is/are dependant upon me.

(Signature is not required as the document is to be digitally signed)

 The Employees' Pension Scheme,

PART B (EPS)
(Para 18)

I hereby furnish below particulars of the members of my family who would be eligible to receive
widow / children pension in the event of my death:

Relationship with
Sl. No. Name of the Family members Address Date of Birth
the member
(1) (2) (3) (4) (5)

1 SHIV PURAM COLONY, SISAI 14/03/1975 Wife

MALA DEVI
AADHAAR: XXXX XXXX 4223
Bank A/c:
692200170000XXXX
IFSC: PUNB0692200
WARD NUMBER 3, KICHHA,
UDHAM SINGH NAGAR,
UTTARAKHAND, 263148

2 SHIV PURAM COLONY, SISAI 24/06/2004 Daughter

KIRAN YADAV
AADHAAR: XXXX XXXX 7095
Bank A/c:
692200150001XXXX
IFSC: PUNB0692200
WARD NUMBER 3, KICHHA,
UDHAM SINGH NAGAR,
UTTARAKHAND, 263148

3 SHIV PURAM COLONY, SISAI 22/05/1999 Daughter

SHOBHA YADAV
AADHAAR: XXXX XXXX 5259
Bank A/c:
692200150000XXXX
IFSC: PUNB0692200
WARD NUMBER 3, KICHHA,
UDHAM SINGH NAGAR,
UTTARAKHAND, 263148

*Certified that I have no family as defined in Para 2(vii) of the Employees' 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 under
para 16(2)(a)(i) and (ii) in the event of my death without leaving any eligible family member for receiving

Relationship with the member

Name and Address of the Nominee Date of Birth

-- -- --

Date : 25-Dec-2022

(Signature is not required as the document is to be digitally signed)