FORM – 2 (revised)

EMPLOYEES’ PROVIDENT FUND ORGANISATION

NOMINATION AND DECLARATION FORM Emp ID:__________

FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme.
(Paragraph 33 and 61 of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’
Pension Scheme, 1995)

1 Name (in Block Letters) 7 Permanent Address

2 Father’s/Husband’s Name .
(in case of married Women)

3 Date of Birth
Temporary Address
4 Sex

5 Marital Status

6 PF Account No

PART-A (EPF)

I hereby nominate the 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 event of
my death:
Name & Address of Nominee’s Date of Total amount or If the nominee is a minor,
Nominee/s Relationship Birth share of name relationship and
with the accumulation in address of the guardian
Member Provident Fund to who may receive the
be paid to each amount during the
nominee minority of nominee
1 2 3 4 5

1. *Certified that I have no family as defined in para 2(g) of the Employees’ Provident Fund 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 dependent upon me.

*Strike out whichever is not applicable. Signature/or thumb impression of the subscriber
FOR OFFICE USE ONLY

Dt. of Joining E.P.F / /20 . . ENTRIES VERIFIED

Past Service ______________ Year

D.A S.S A.A.O
Date of Joining EPS / /20
 PART – B (EPS) Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive
widow/widower/children Pension in event of my death.

SI. No. Name of the family Address Date of Birth Relationship with member
member
1 2 3 4 5

1.

2.

3.

4.

**Certified that I have no family, as defined in para 2(vii) of 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 pension (admissible under para 16 (2) (g) (i)
& (ii) the event of my death without leaving any eligible family member for receiving pension.

Name & Address of the nominee Date of Birth Relationship with the member

Date:

*Strike out whichever is not applicable. Signature /or thumb impression of the subscriber.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by
Shri/Smt./Kum. employed in my establishment after he/she has read the
entries/entries have been read over to him/her by me and got confirmed by him/her.

Signature of the Employer or other authorised Officers of the Establishment

Designation

Date:……………. Name & Address of the Factory/Establishment or Rubber Stamp thereof.

 Emp id : _______________

FORM - F
(See Sub-Rule (1) of Rule 6)

NOMINATION
To
M/s.

(Give name or description of the establishment with full address)

I Shri/smt./Kumari..............................................whose particulars are given in the statement below, hereby

nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity
standing to my credit in the event of my death before that amount has become payable or having become
payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against
the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause
(h) of Section 2 of the Payment of gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section 2 of the said act.

4. (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the ________________ to the Controlling
Authority in terms of the proviso to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)
Name in full with full Relationship with the Age of Proportion by which the
address of nominee(s) employee Nominee gratuity will be shared

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

1.

2.

3.

4.

Statement

1. Name of employee in full :

2. Sex :

3. Religion :

4. Whether unmarried/married/widow/widower :
5. Department / branch/Section where employed :

6. Post held with Ticket or Serial No., if any :

7. Date of appointment :

8. Permanent address :

Village _____________________ Thana _____________

Sub-division ______________

Post office __________________ District ____________ State ___________________

Place : Signature / Thumb-impression

Date : of the employee:
Declaration by witnesses
Fresh nomination signed / thumb-impressed before me.
Name in full and full Signature of witnesses
address of witnesses

1. 1.

2. 2.

Place:
Date :

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer’s reference No., if any.

Signature of the employer / officer
authorised designation
for

Authorised Signatory
Name & Address of the establishment /
Rubber-stamp thereof

Acknowledgment by the employee

Received the duplicate copy of nomination in Form F filed by me and duly certified by the employer.

Date : Signature of the employee

Note : Strike out the words/paragraphs not applicable.

NOTE : Please retain with you for any change in marital status at a later date
 Declaration of Nomination Form
I, ____________________________, Employee ID ______, Location - Bangalore/ Pune/ Hyderabad hereby
nominate the person(s) mentioned below to receive the amount outstanding to my credit in the event of my
death pertaining to:

1. Full and final settlement from Citrix

Nominee(s)

Name & Address of Nominee(s) Nominee’s Relationship Age of Nominee Total amount or share
with the Member of accumulation to be
paid to each nominee

2. Group Personal accident Insurance

Nominee(s)

Name & Address of Nominee(s) Nominee’s Relationship Age of Nominee Total amount or share
with the Member of accumulation to be
paid to each nominee
 3. Group Term life Insurance

Nominee(s)

Name & Address of Nominee(s) Nominee’s Relationship Age of Nominee Total amount or share
with the Member of accumulation to be
paid to each nominee

Acknowledgment by the employee

Signature/or thumb impression of the employee

Employee ID: _________

I authorize the management to make the payment to the above nominee(s) in case of my death and as such I
discharge the management on making the payment which was due to me.

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment

Authorised Signatory
Name & Address of the establishment/
Rubber – stamp thereof
 Emp ID:_____

<< JOINT DECLARATION SHOULD BE PRINTED ON THE LETTER HEAD OF THE ESTABLISHMENT>>

JOINT DECLARATION UNDER PARA 26(6) OF THE EPF SCHEME, 1952

[Form to be used for : 1. Enrolling an ‘excluded employee’ as a member of EPF Scheme, 1952; and
2.Remitting Voluntary PF Contribution by a member – i.e to allow an existing
member to contribute towards PF on more than Rs.15000/- of his ‘pay’ .]

(Refer Paragraphs 2, 26, 26A, 29, 69 of Employees’ Provident Funds Scheme, 1952)
*******

To
The Regional P.F. Commissioner,
Regional Office, Bengaluru (Central)
Declaration by the Employee

I, _______________________________ , son/ daughter of _________________________

hereby declare the following.

(Strike-off whichever is not applicable/ Print only whichever is applicable)

1. For enrolment:

(a) I have read and understood Para 26(6) and definitions of ‘pay’, ‘excluded employee’ under Para 2 of EPF
Scheme, 1952. Accordingly, I declare that I am an ‘excluded employee’ as per Para 2(f)(ii) of the Scheme and
is not enrolled as a member to the Scheme till now as my ‘pay ’/ ‘PF wage’ from the date of joining an EPF
covered establishment has been above the statutory wage ceiling of Rs.15,000/-. Now, I wish to become a
member of EPF Scheme, 1952 w.e.f. _________ and hereby exercise my option for the same.

OR

(For those members who join employment again after superannuation)

(b) I have read and understood Para 26(6), definitions of ‘pay’, ‘excluded employee’ under Para 2 and Para 69
(1) of the Scheme. Accordingly, I declare that I am an ‘excluded employee’ as per Para 2(f)(i) of EPF Scheme,
1952 as I have already withdrawn my full PF accumulations in the Fund under Para 69 (1) (a)/ (c). Now that I
have again joined a EPF covered establishment, I hereby exercise my option to become a member of EPF
Scheme, 1952 w.e.f. _________.

2. For voluntary contribution on higher wages

(a) I am an existing member of EPF Scheme, 1952 bearing PF Account Number

BG/BNG/_________/______) under UAN ____________________. I have read and understood Para 26(6)/
26A/ Para 29 and definition of ‘pay ’ under Para 2 of the Scheme. I wish to contribute towards PF on higher
wages/ at higher rate and hereby exercise my option to contribute to Employees’ Provident Fund on more
than Rs.15,000/- (statutory wage ceiling) of my pay per month w.e.f. ___________.

(b) Rate of contribution :

(i) I exercise to contribute on 12% of my entire ‘pay’ / ‘Gross wages’ as in ECR; OR

(ii) I exercise to contribute on 12% of my entire ‘PF wage’ as in ECR; OR

(iii) I exercise to contribute on ______% (can only be higher than 12%) of my ‘pay’ / ‘PF wage’/ Rs.15,000/-
under Para 29 of the Scheme.
3. For enrolment and voluntary contribution – Fill up both 1 & 2 as applicable.

I agree to abide by/ comply with all the statutory provisions of EPF Act, 1952 and Schemes framed
thereunder. Therefore, kindly approve the option exercised by me under Para 26(6) of the Scheme along with
my employer. I also understand that the option exercised by me becomes valid only after it is approved by the
competent authority.

Place :

Date : Name and Signature of the Employee

Undertaking by the Employer

I / We, as the employer of the above-mentioned employee hereby undertake to :

(i) Pay the administrative charges payable at prescribed rates towards EPF/EPS contribution made by/ in
respect of the said employee (including that of his/ her voluntary contribution); and also to
(ii) Comply with all the statutory provisions under EPF & MP Act, 1952 and Schemes framed thereunder in
respect of such employee with effect from the date of option mentioned above as exercised by the employee.

2. Copy of Form-11 submitted by the member at the time of his/ her joining and Salary Slip/ statement in
respect of the member for wage month ________ (both duly attested) are also enclosed herewith for
verification. (Ex : if Date of Option by member is 01.06.2021 (May paid in June contribution), enclose salary
slip for wage month May 2021).

Place : Name and Signature of the Employer/

Date : Authorised Official with Seal.

For EPFO Office Use

The Joint Declaration in respect of Shri/ Smt/Ms. _______________________ [UAN : _________________ ;

PF Account No. : BG/BNG/__________/_________ ) under Para 26(6) of the Scheme for enrolment/
voluntary contribution is accepted herewith w.e.f ___________.

Regional/ Assistant PF Commissioner (Accounts)

(Name and Signature with Seal)

To

1. Shri/Smt/Ms. __________________________ (Through the employer)

2. M/s. ________________________________________________________
3. RPFC/ APFC (Enforcement)

IMPORTANT POINTS TO BE NOTED WHILE SUBMITTING JOINT OPTION UNDER PARA 26(6) OF EPF
SCHEME, 1952

1. Excluded employee -
2. Pay –
3. Gross Wages –
4. PF Wages –
5. Statutory wage Ceiling – Rs.15,000/- or as applicable from time to time.