IFFCO TOKIO Employee’s Provident Fund Trust Nomination Form

I, VINEET UTTAM TIBREWAL, hereby nominate person(s) mentioned below to receive the amount
which has become payable or having become payable has not been paid; and direct that the said amount
shall be distributed among the said person(s) in the manner shown below against their names:

S. No. Nominee’s Name Address of Nominee Relationship Age of Share in

with member Nominee fund (%)
1 ANITA UTTAM 1104,MangalKripa,Unnat Mother 58 100%
TIBREWAL Nagar2, Opp Patkar College
Goregaon west
Mumbai 400104

That in the event of my death during the minority of above named nominee, I hereby direct that the
person(s) whose particulars are given below shall be deemed to be the guardian of the minor nominee for
the purpose of the

IFFCO TOKIO EMPLOYEE’S PROVIDENT FUND TRUST.

S. No. Minor Nominee’s Name Age of Guardian’s Name & Address Relationship
Minor

Date: 13-December-2022

Place: Mumbai Signature of the Employee

Certified that the above declaration has been signed/ thumb impressed by ____________________
employed in our establishment/ factory after the entries are read by him/ her, have been read to him/her
by us.

Date:

Place: Signature of the Employer