SPECIMEN Form No. 11 (New) Declaration Form (To be retained by the Employer for future reference) Employees’ Provident Fund Organization ‘THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57) & ‘THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24) PROVIDENT FUND SCHEME, (PLEASE GO THROUGH THE INSTRUCTIONS) 1) Nawe (Tm) fe MR. | MS. | MAS. (PEASE TICK) 2) DaTe oF BrRTH DPOPMIN|Y|Y[ uy 3) Famer’ useano’s Nave [ME 4), RELATIONS WRESPECT OF (3) ABOVE (Please T109) 5) GENDER (Please Ti) 6). Moone NuNBER (iran) 7) EMALID (IF any) FATHER HUSBAND: FEMALE | TRANSGENDER ie 8) WHETHER EARLIER A MEMBER OF THE ENPLOVEES’ PROVIDENT FUND ScHEVE, 19527 9) WHETHER EARLIER. A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995? (Please Trex) (Puesse Ticx) YES NO YES NO '¥ nEsponst To awy om BOTH OF (8) & (9) ABOVE 1s YES, THEN MANDATORILY UP Tie PREVIOUS EMPLOYMENT DETAILS AY (10,118 12): Page 1 of 3Previous PF Memser 11) Dave oF Barron previous ‘Mesaer ID (DD/MM/YYYY) 1D ESTABLISHMENTID [ EXTENSION | AccOUNT NUMBER Sree trer 12) _(A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER, (6) IF PENSION PavMeNT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER: 13) IvTERNATIONAL WoRKER (Puease Tiex) Ys No. IF THE REPLY TO (13) ABOVE 1S YES, THEN ENTER THE DETAILS IN. 13(A), 13(8) & 13(c): 13(9) Coury oF ORIGIN (Please Tick) TNO ‘OTHER THAW INDIA (IFES, PLEASE [MENTION NAME OF THE COUNTRY) 13(8) PASSPORT NUMBER’ 13(¢) Passponr vauo Fer SETAE To Di/o|mM|[mlyY]/yY]yY yy 14) EoucarIOnA. Non] 5 SEWOR Post TECHICALT QUALIFICATION ear, Marrac [MATRIC ‘seconoary | GHOUATE | Gapouare | DOCTOR ‘PROFESSIONAL (Pease 109) 15) Manara Srarus MARRIED __]UNVARRIED | Wibow/ WioweR | DNvORCEE ] Manelatorry — (PEASETIO) 16) srecany Ane vs] 80 TEV, Tk THE CATEGORY (Pease Tog Loconorive | Visual Hears Page 2 of 317) kyC Devas [KYC DOCUMENT TPE Bank ACOOUNT-1* NPR/AADAAR PERMANENT AGOOUNT Numer (PAN) PASSPORT 5 Daivine LICENCE ELECTION CARD TRATION CARD ESIC CARD * Mandatory Field (NOTE® BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) 1S MANDATORY. YOU |ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU ADDITION TO MANDATORY KYCS TO AVAL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST SE ATTACHED WITH THIS FORN, CUNT GLEE SS RTS AA. CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. INCASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995, (1) Have ensuneD THe CORRECTNESS OF MY UAN/ PREVIOUS PF MENER 1D, (i) Tits may aLso BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM ‘THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE ONLY IF THE IDENTIFIED! KYC. DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT EMPLOYER USING HIS DIGITAL SloNATURE CeRTiFicaTe). (C11) Am Awake THAT I CAN SUBAIIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTA REMARS, IF ANY sw» AND HAS BEEN ALLOTTED PF MEMBER 1D B. _INCASE THE PERSON WAS EARLIER NOT A/MEMBER OF EPF SCHEME, 1952 AND EPS, 1995: + (POST ALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER IS. ‘+. PLEASE Tick THE APPROPRIATE OPTION: “THEKYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE DHAVENOTBEEN UPLOADED HAVE BEEN UPLOADED BUT NOT APPROVED [D_» HAVE BEEN UPLOADED Ano APPROVED WITH DSC CC. _ INCASE THE PERSON WAS EARLIER A MEMBER OF EPF Scrette, 1952 aND EPS, 1995: ‘©THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED WITH HIs/HER UAN/PREVIOUS [MEMBER ID AS DECLARED BY MEMBER. ‘+ PLEASE TICK THE APPROPRIATE OPTION: (THe KYC DETAILS OF THE ABOVE NENBER IN THE UAN DATABASE HAVE BEEN APPROVED WITH DIGITAL SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL, AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MENOER HAS BEEN INFORMED TO FILE PHYSICAL CLAIM (FORH-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT, ‘SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT Page 3 of 3FORM ‘F” [See sub-rule(1)of rule 6) Nomination [Give here name or description of the establishment with full address] I, Shri/ Shrimati/ Kumari. statement below, whose pa lars are given in the (Name in full here] 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(). 2. Lhereby 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. Thereby 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 dependant on me. () my husband's father/mother/ parents is/are not dependant on my husband. 5. Ihave excluded my husband from my family by a notice date the ...... to the controlling authority in terms of the proviso to clause (h) of section 2 of the said Act. 6. Nomina: n made herein invalidates my previous nomination. Nominee(S) tae MANDATORY Name in full Relationship ‘Age ofnominee | Proportion by with full address | with the which the ofnominee(s) | employe gratuity will be shared TL a 3 0 on.Statement Religion. HWNDv Whether unmarrisd/ married/ widow/ widower. > maidatery, 1 2. 3 4. 5. Department/Branch/ Section where employed. 6 7 8 - Post held with Ticket or Serial No., if any. Date of appointment. 4 . Permanent address. wah, © Bhock ,Govircl tyes, lanpus ~209609 SAYA L ohana. SHIAMPYERs, Post Office. .R AM EYE ub-division . Place Signature/ Thumb impéession of the employee Declaration by witnesses Nomination signed/ thumb impressed before me. ‘Name in full and full ~ Signature of witnesses 1, RAM PRATAP SINGH a he 2. Say mm SoeH 2 ae 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 authorized Designation Date Name and address of the Establishment or rubber stamp thereof. Acknowledgement by the employee Received the duplicate copy of nomination in Form filed by me and duly certified by the employer. Date Signature of the employeeFORM 2 (Revised) NOMINATION.AND DECLARATION FORM FOR UNEXEMPTED/ EXEMPTED ESTABLISHMENTS. Declaration and Nomination Form under the Employees’ Provident Funds and ‘Employees’ Pension Scheme (Paragraphs 33 8 61 (1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension scheme, 1996) 1. Name (in Bock eters) Beye 2. Father's*Husband’s Name. SHRI RAM PRATAP SINGH 3. Date of Bith Oy \ra} 198° fee ‘ MALE 5. Marital status 6. Account No. 7. Address Permanent Viwb + pos r--cHY¥AmPUR BIST=RAMPOR Tame 2 Spahr ene aati 8. Date of joining MYMBAE — UTE 20) PART—A(EPF) MANDATORY ‘hereby nominate the person(s) /eancel the nomination made by me previously and nominate the person(s) mentioned below {o receive the amount standing to my credit in the Employees’ Provident Fund in the event of my death ‘Name of omnes! Adsross Nominee'srelaton- Dale of Total amount of share of the nomines i a minor, ominees ship withthe member Birth ‘Accumulation in Prov ‘name & relationship & adress ent Fund tobe pad to ‘ofthe guardian who may ‘each nominee focaive the amount during the minority of nominee 1 2 3 4 6 6 11 * Cortfiod that | have no family as defined in para 2() of the Employees’ Provident Fund Scheme, 1952 and should "acquire @ Family hereafter, the above nomination shoud be doomed as canceled. 2 *Certiied mat my faterimother sare dependent upon me. ae ‘Signature or thumb impression of the subscriber “trike out whichever is not appicableAteccines Part B (EPS) (Para 18) MANDATORY | nereby furnish below particulars ofthe members of my family who would be eg to receive widow'chldren pension inthe event of my death, SNo. Name ofthe family ‘Aséross Date of Bith Relationship wth the member ‘member 7 a 3 a 3 1 2 3 4 5 6 * Certed that have no family, a defined in para 2(vi) of Employees’ Pension Scheme, 1995 and should | acquie a family ‘hereafter | shall furnish particulars thereon in the above fom, 'nereby nominate the folowing person for receiving the monthly widow pension (admissible under para 16 2(e\) and (i) in he event of my death without leaving any eligible family member for receiving Pension. manoaTorY ‘Name and Adress ofthe Nominee Dato of ath Rolaonship wih the memba 1 2 3 1 2 3 ms ge Signature or thumb impression of the subscriber “Sirk out whichever s not applicable. CERTIFICATE BY EMPLOYER Certified thatthe above declaration and nomination has been signed/thumb impressed before me by ShvifSmt/Kum, ‘employed in my establishment after he/she has read the entris/entes have been read over to hinvher by me and got confmed by hire. Place Signature ofthe employer or thor ‘Authoried Officers of the Establishment. Designation Dated the: Namo & Address of the Factory! Establishment or Rubber Stamp TheroonSPECI MEN ‘dla 4 DECLARATION FORM. ‘erh/Formt ster oe ate rer wer ae | wef ane tec ere ot eta oA TE oT aT OM A Te hes yes We tg Reet at we we aor afte ae an Fes B ‘Tobe filed by employee aftr reading instruction averoal, Two Postcard Size phographs tobe attached with the orm. This form i re of cost (@) dag aes 3 fear (@) frie & Baer (A) _ INSURED PERSON'S PARTICULARS (@)__ EMPLOYER'S PARTICULARS insurance No] 8 [. Retiaw a ae dom 1. ater Wet insurance No] B age cacriarstea na’ 2am Ge awe ®) | SuRvaPRATAPSIN GY | TR a ate | aie oat Dat Apple ay | Moan | Year S-Ravaft am [Sues Ram PRA rap Sine | anda ic and bal Date of Bith Day} Mont Yea} aes | afeaa fires er et SR aaa A Adesso Eployer eee yA Moat = (a) Pde ae som 80 oer | * eoreran] {emer ose. facie BCISTEIST | pcre SETA) faye waa aaa sexta eet ered Ser (c) Name & Address of the Employer eer ere eae Bach Ofee Dapersay eet eevee acres (©) ea Hae see rer & Ree eae, oe Wa nL (Ble Po, 1560 & F262) oar wy (© Deiats ot Nominee wis 71 of ESI Act 194/Rule-S0(2) of ESI (Central) ues, 1950 for payment of cash beneftin he event of dean, MANDATORY wane i Reltonsip TaUACEIOSS 8 car te era rng Re Fen seer ewe ew 1 A ee er we ga Lane area oe cone orga Bais an ‘hereby declare that paras gen by me are conc tothe best ny owe and bl. undenak to intmate the ceperaton ny Changes nthe membership my amy win Ye dae a eich arg. Fries # ame erp ates cereus Fert (Courter signature by he empioyer ‘Signature Tht ‘ie ta wee ‘Signature wih sal (org eer ot Pare (0) Fanty Paicalarsotinsures parson ee a widata | cidtarad | wstese | aaa Ist No. Name Sargareatta | Reatinenp win ine wh et are ait Jost ot Brevage as on Enployee Wwetnereocing |’ Ir no's Pace ot at fing frm inthe Hinia_| Sav Town | 1S | era, fom ae ea (Papas oh ante fh 2) ESI Corporation Temporary ent Card (Wald fr 3 month tom the ct of appoint) were Fer Fane No. Bigs athe Oat ol appomimont ‘war ee rere a ie Branch Oes Dispensary (Space fr photograph) awe @ a ten or Employers Gove No. & Adress ta vay ge oe ‘Gouge ees @ Yeas Pet ‘te afte en tae ran Dated SignatreT-ot LP ‘Slate of BM. wih ea!SPECIMEN FORM NO. 1288 (See rule 260) ‘Statement showing particulars of claims by an omployee for deduction of tax under section 192 [i Name and address of he employee fz: Permanent Account Number (PAN) ofthe employee: Location SRO SEAS Doyen Gos [a Financial year” Bae Details of claims: evidence Thereot is Wature of claim No Details “Amount Evidence7 (Rs) [particulars Ico @ a @ @ [| House Rent Aowance: Rent gai to the landlord |W Name of the andor i Adress of te lanors [Permanent count Nomber ofthe andlor Note: Permanent Account Number shel be fuished fhe lagoregate rent pad tring the previous year exceeds one lakh rupees [2 [Leave travel concessions or assistance WA [5 [Deduction of intorest on borrowing: [onterestpayeble/ped to he fender [epName ofthe ender [a Adore ofthe ardor (w) Permanent Account Number of a) Francia! netutone(t avaiable) ()Empioyer(favaabe) [le Others [a [Deduction under Chapter VIA [Section 896-8006 ana s0CCD I) Section 0c [paid under Penson Scheme of nsrance Companies [Deduction Under New Pension Scheme. PS Insc Fos for Chron con a os Coa lowing Lon Principal Amount Repayment insurance Pret PailPayabe remse p incy oe lnsetermssesuse sche ve Year Bank Fixed Gepost ox Tr Eg Fe tl Fund hex et [Sukanya Yoana [Ebr & Voluntary PE Gots ey compan lw) Section socce. i) Section socco. 5 [Other sections (e.g, 800, OE, BOG, BOTTA, eta) under [@, SECTION (o) tsaea Trance Prom: Sal axe [z)S=TION (00) toceal insurance Premium eden fens ro war rrr cee Pann sa nl by un section oe) wighr Education Loan intrest Repayment rial Medal Be ai ET Verification hereby declare that have invested invest the amount mentioned above during FY 2017-t8and shall be liable for any iabitty arising out of any discrepencios in the above declaat Pace MAUR ST pate. Ary] 8a) A018 Gennaio OY [Desgraion SO fultene. ips PARTS SING |