Form2 (Revised)

NOMINATION AND DECLARATION FORM

FORM UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employee's Provident Funds.
(Paragraph 33 and 61 GI(1) ofthe Emplyee's Provident Fund Scheme, 1952 Paragraph 18 of Employee's Pension Scheme, 1995)

Personal Details

Personnel No 00503092 Name RAJESH KUMAR TIWARY

Father's Name BHARAT TIWARY Department Operation 51184557
Post/Desig. SENIOR ASSOCIATE PO0L1079 Date of Joining 01.07.1996
PAN No AAZPTO8o0C UAN No
Gender Male Date OF Birth 05.07.1973
Marital Status Married Status Pending for signed copy uplad
Address 315 BRIJBIHARIBAGAN BHALUBASA
PART-A (EPF)
There by nominate the person(s) / cancel the nomination made by me previously and nominate the person(s) mentioned bclow the
receive the amount standing to my credit in the Employee's Provident Fund in the event of my death.

Srl No Nominee Name Date Of Birth Sex Relation Guardian % of Share

1Shashi Kiran Tiwary 28.08.1971F Spouse 100.00
Photo ID Type Photo Id No Mobile No Address
Aadhar 394743430487 7903908594 House No-315, Brij Bihari Bagan, Slag Road, Bhalubasa
Jamshedpur-831009

1. I certify that all the details entered by me are valid and correct

2. I certified that my father/mother is/are dependent upon me.

RK wa
RAJESH KUMAR TIWARY
Nomination Filled on 22.12.2021