(FORM 2 REVISED)

NOMINATION ANDDECLARATION FORM FOR

UNEXEMPTED/EXEMPTED
ESTABLISHMENTS
Decaatinand Nm natin Pom xer the Em plmve Prviknt Fnds and Em pbyers
Pensirn Sdm es
Patagnqph 33 ad61 a) of the Bm pls P r t dSdem e 1952 ard Parnxapth 18 of the Em prS
Pensin Sme 1995)

1.Nme (N BLOCK LETTER S):

RAJAN
Name Fattr'a /Hutd'aNm
SINGH Sumam e

2.D ae ofB ath : /02[/997 .Ant No4 36002|2ODo|014

4.*Sex :NALEAEN ALk MALE 5.M atal Stat UN MARLLS
6.AdiPematTen poary : 4ARwAH, JAUpR, UTIAR PRASES M
223/3

PART-A(EPF)
s) mentined bew
hety nn nar he peRns e l the Nmhatim made by mepeviusly ad nm nate the pern
tENe the nant saig omy ait n the Em pbyes Povdent Fund, n the eventofm y death.
If the nam nee sm nor
Totalam auntorhare of nam e and addess of te
N aeof te Nam hee's D ate of
accumuatins n quadian w ho m ay eeve
atinshp wh B ith
PvientFunds to be the am ountdurg he
he m em ber
pad to each nam nee m norty of the nom nee

5 6
3

SHYA GARAt FATHR-c

19S
C7TAR

1223/3

of the Empbyees Povdent Fund Shen e 1952

and stoud I
efed hat Ihave no fam îy as defned n paa 2 g)
outbe deem ed as canceled.
aguea an yheafter he above nom inatin

Cerfd hatmy fathertn otther sae depednt upanme.

Srieautwhteve sotpabe
Sipauebr thum b n peeon
of the abarber

PA RT EPS)
Paa 18
elybe to aeve W dow Chiten Penann nhe
nen besof my fan ly who WOuh be
Ibey furg bex patuas of the
eventaf n y p4 atut dah n rve.

Rektup w ith the n n ber

SrNo Nane b AisS of te Fau iy Men be Age

3) (4)
2)

1) TATHCR
VTIAR PRADÉH -223)o3
Cetihad that I have no fam iy as defied n paa 2 (vi) of the En pbyees's Fan iy Pensin Sceme 1995 and toud lauæ a
fm iy heeafter Ihall fmih Partiauks thee on in the above fom

Ihereby nm nate the folbw gpern for cevig the manthv w iw pensin adm ssbe under para 16 2 (a) & ) n the
eventofm ydeath withaut kvig æy eliybk fam iy mem ber for ieceing pensicn.

Nameand Addieg of D ate ofB nth Reatirnhpw th n em ber

the mhee

SAY Am FATHE2
GAIRAH, JAUNPUR,
UTTA PRAeSH;223|03

Date

Sinatue or thumb n presm

of the absrber

CERTIFICATE BY EMPLOYER

Cerifed that he above declaration and nam nation has been signed / thum binpresd before me by Shri / Sm t
M S5 em pbyed inmyestabitm ntaferhete has
Esd the entres /the enties have bean ead overto him herbyme and gotonfim ed by hm her.

Date Sinatue of he empbyerorother authonædoftrerof the

establihm ent

Plae:
Nam e & addesof the Factory Esablim ent
D ate :