Employee code

{Mandatory)
/Ii FORM 2 (Revised1J]
Entity Deloitte r ouche Tohmatsu
(For Uflexemrtect /Exempte<I E'1tabllshm"?nts) F1111 r:t111n Cr::,n'3tilllng

NOMINATION AND DECLARATION FORM

(Declara!ion and Nominal,on Form under lhe Employees Provident Funds and Employees· Pension 3r:heme}
(Paragraphs 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 and paragraph 18 of the Employees' Pension Scheme, 1995)
1 Name (in Block Letters) JINKAL SAJJANKUMAR PATWARI

2 Father's/Husband's Name SAJJANKUMAR DHARAMCHAND PATWARI

3 Date of birth .• OS/03/1989

4 Sex : Male
5 Marital Status : Married
6 Account No. "'' ., ,:, •v,,,,,1,,•,1 101109145846
7 Address 1-1<n1di:111,,,o • Permanent BHANDUP

Temporary

PART A (EPF)
I hereby nominate the person(s)/cancel the nomiriation made by me previously and nominate, the person(s) mentioned
below to receive the amount standinq to my credit in the Employees' Provident Fund in the event of my death·
'
Name and Address of the nominee/ nominees Nominee's Date of Total amount or If the nominee is a minor,
relationship with Birth share of name and relationship
the member accumulations in and address of the
I
Provident Fund to guardian who may receive
be paid to each the amount during the
nominee(%) minority of nominee
i
(1) (2) (3) (4) (5)
1) DEEPIKA PATWARI Spouse 16/12/1988 50 I
P-2103, SRISHTI HEIGHTS, LBS MARG, BHANDUP WEST

2) SAJJANKUMAR PATWARI / Father 03/12/1966 50

I
P-2103, SRISHTI HEIGHTS, LBS MARG, BHANDUP WEST
I l) I I

4) I I
l
5) I I

I ~ooOJo
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 dependent upon me.
3. * Strike out whichever is not applicable.
----------------------------------------------
Signature or mb impression of the subscri.ber
Note: _ A Fresh nomination shall be made by the member on his marriage and any nomination made before such marriage
shall be deemed to be invalid
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No111i11,11ion-For111 (004)
 1
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 m death. Relationshi with the member
Date of Birth
SI.No. Name and address of the famil members
3 4
1 2
DEEPIKA PATWARI 16/12/1988 I Spouse
1
P-2103 SRISHTI HEIGHTS, LBS MARG, BHANDUP WEST
'

5
** 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 persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii)
of Employees· Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving
Pension.
Date of Birth Relationship with the member
Name and Address of the Nominee --+-------=-----------;
(1) 2 3
SEEMA P.l-. TWARI

P-2103. SRISHTI HEIGHTS, LBS MARG. BHANDUP WEST 01/06/1969 Mother

SAJJANKUMAR PATWARI

P-2103 SRISHTI HEIGHTS. LBS MARG, BHANDUP WEST 03/12/1966 Father

Dated the : 12/4/2023

e or thumb impression
of the subscriber
**Strike out whichever is not applicable.
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kumari JINKAL SAJ~ANKUMAR ~ATWARI employed in my establishment
after he/she has read the entries/the entries have been read over to him/her by me and got confirmed by him/her.

Place:
Dated the 12/4/2023
Signature of the Employer or other authorised
Officer of the establishment
Designation ............................................ ..
Name and address of the Factory/Establishment
or rubber stamp thereof

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2 nm rri d - T Paren s Bro her is er r an o h r er on s .
Nu111i11:11io11-Fnr111 ( 004)