‘COAL MINES PROVIDENT FUND ORGANISATION wire are after fae TST town omen (Nomination under Para 62 of CMPF & Sub Para (1)&(2) of Para(5) of CMPS'98) | ime. runnen mu 0 (eearcroor er 62 at erearthrar 98 eer (5) # 3 er (1) Ce (2) & sieraha)| Mone Omer 3 cater Ferree othe at oR oe ‘A. PERSONALINFORMATION (Sl.No. 1 to 12 is mandatory): freee at eet wer © cafe acer (wr i. 1 12 aw strat & rete TEMP ATEN. (To be left blank in case of new employee) star a dar det (ae acted 1 fafa a feat car se) 2 EMPLOYEE NAME (IN BLOCK LETTERS) apart ar a (ie st #) 3. FATHER'S/HUSBAND'S NAME favefa a art 4. DATE OF BIRTH OF EMPLOYEE apaentt & sea FAR 5. UNIQUE IDENTIFICATION MARKS: Patties agar Pee &.__ DATE OF APPOINTMENT rafter & ART 7. MARITAL STATUS. | tents fete 8. PIS No./EMPLOYEE NO. tt anf wa aear/actertt veer 5. AADHAARNO, # sme aeat 10. PAN NO.# ta deat TI, SALARY BANK ACCOUNT DETAILS (PREFERABLY F& S MODE yeas (ives: oF ts ww 3h 12. CONTACT / MOBILE NO. ah Alarge eT 13. EMAILID $F gs Continued... ...B. NOMINATION STATUS ("THi@7 Ret): ‘Name of the Nominee: ‘Aadhaar No. of Relationship a —— ‘Share in mnt wre nominee | withnominee | Memow/vonioas | (ocselmior | percentage sig arom | tea wore | ewer | adore er on | RU (remeron) | prem nomrst | eer m8) Terr 7 ‘ew 8 re 2 3 Tarremee —[ (seo & ce 2 Serene oe eotwee |3 = “Thereby det Tor payment of amount of my een the Coa Mines Provident Fund atthe te of my death tothe above persons in the manne shown asin thei nore A wea ANY AY A Ra wT er FA AAT cad a gam att at ster aaah sah ae Gah) & so Fae at eae so ar Per erect ** inereby declare that above information furnished by me i correct, 2nd any ntrmation furised ealer may be treated 35 canceled. A caer ae utente € A A ear Sete Aa ag arent ath & ate gt tae gare & ag fet ot aaerth Y PACET AAT STE | (Signature/thumb impression of the incumbent/member) erceaioner 1 PeRMET/IeS Per records ofthe employee and certified to be correct. ‘ae wears rat ara | (coin aftetetet ate er FEET) ‘The above particulars of the employee have been verified from the service seater sotert er ser Reecor see tar ah & eer ror foe (signature/Seal ofthe Authorized Oficer/Colery Manager) “the employees consent for poyment of PF/Pension to the Nominees at wt we are fe aorta er ‘1 The consent of employees for change of Nomination aie Rta a ee otra a Copy of AAdhaar and PAN of self end nominee(s) must be attached ea ee anPiara) & sure wat tt aA (ACKNOWLEDGEMENT) (srftrectepfay Nomination Form in ¢/o Sri/Smt. ivi 3% aaer A arate ort MPF areries employed at Colliery Registration at aifeett dst a. 3 in favour of, — (PF) & oe F (dre) Pension) has been acknowledged. (Gat) eaten Pear rare | Signature & Seal of Authorized Officer of CMPFO Prearhepst F step stra ar KeATANTRTCLAIM FORM FOR PF REFUND AND PENSION safer Fae arvatt we Gert aren & fare vt (For all kinds of PF & Pension Claims) ‘pat war & afte fa ed Get grat & fare ‘NEW SAHA!’ SLNo] PERSONAL INFORMATION me aan foc coors nae ‘or claimant. Photograph | NAME OF MEMBER (in Block Letter) Se ascariee ey aaea wT are (ease HART Hi) ‘Authorized Officer of Colliery 2 | FATHER'S/HUSBAND'S NAME Management. oS LET ye secant wt tit 3. | CMPFA/CNO. Sa wen’ wr wet ara yf aor eer Rover’ at aiet weer & «| PIS No,/EMPLOYEE NO. after tert ar tt ang va dea/atart Feat afremetearatiremfre Ft 1 5. | COAL SOCIAL SECURITY NO. ate arate ear eee & | AADHAAR NO. UR HT [7 [PAN No. ae z fa som orphan of Meret & | EMAILID Jointly with spouse. iv stored oer ter 3. | CONTACT/MOBILE NO. Management. ak | ararge sear 30. | DATE OF BIRTH eee wer Sah Be er erent are wT wet faaiea & fae sree reer #1 | DATE OF CESSATION warts # far 33. | DATE OF DEATH manana aay Ft AR et ary rcs NAME OF SPOUSE/CLAIMANT se/ seat | erat aT cc “AADHAAR NO. OF SPOUSE/CLAIMANT | sti/seeft | ererareth ar are aT "AN NO. OF SPOUSE/CLAIMANT a/aed | crarect & ta sear T RELATIONSHIP WITH MEMBER were & ory Hat Continued.../ Fe:38, DETAILS OF SERVICE: tar & Reever ane oF ONT TEGITRATION NO. GM ToaTET [oo ena tit ‘ten deat * = age TEASEENC GSES ARATESREET OFT @ He ED 13, TOTAL RECKONABLE SERVICE 1 UPTO37@9 2. FROM 373070, JF omar aa 13/897. 2 300 = 20. AVERAGE NOTIONAL SALARY OF LAST 10 MONTHS (Please enclose separate sheet), iter et ay rt air tom (aT aT ter wt) 21, DETAILS OF FAMILY (FOR PF REFUND & PENSION} To be filed after death of Member eer er or (A er eR ep wR AY Sei A TE ae: TENTH —[ Ae atbe met | Maral inte Tou sonserssens | et membe’ eth anendney tnd of med Be we sseorette tow) Sey ta a ee veer at be eT rm sate it a oh ater bat wu a) Fs clas Rat 5 (Shed "C i oath aes (aharever i apicabie). Ag oe A er tees See wt (rT AH) (aT HTT A) 2. leas encloe Raf. (wherever Rs appbie pra te-6 daa st Gt a AY 22. Address for correspondence (as per Colliery Records) saree rar (RARE Peer aT) Bank Particulars 1. Name of Account Holder te Reroh ar UT a Name of Bank Branch teow wa 3. SBAICNO. we fe ame 4. IFSCNo. antowert 5. MODE OF OPERATION ‘deren mr ater (8S mode fr empioyee/Single mode for other than employee) (rca Re se at! ce te a Ae we A) 24, Ceriied that above particulars furnished by me is correct and nothing wrong information has been provided by me. | declare that Ihave not remarried ater death of member (in case of widow pension). sonra fran aan BP err er rar ep PT aE we RNG AON a ht EL A a hee TT fe a ce ay cee ee att fort fhe or er AT (Signature/Thumb impression & Name of Member/Ciaiment) (Signature/thumb impression & Name of Spouse/nominee) (weceerererre rarer we PemanTsS Fen) (teeth error ok ears Pe 25. Certified that the particulars of the Employee and that of his/her family are correct and in accordance with the Service Records maintained by the Colliery Management. Further shove particulars have also verted by me and found correct. see fret rer Freee et ore ee or Fron seth waar a tar Penk ogee ae seer Peer At sare carr ret ara ee at ay Ter rat {Signature/Name & Office Seal of Colliery Manager) (eRe dest arr ea te ART)