7/28/2019 Ajay Kumar Singh - Pf No.10

1/2

(For Unexempted/ exempted Establishments)

(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &Paragraph 18of the Employees 'Pension Scheme 1995 )

Declaration and Nomination Form under the Employees' Provident Funds& Employess' Pension Scheme

1. Name 2. Father's / Husband Name

3. Date Of Birth 4. Sex

5. Marital Status 6. Account No.

7. E Mail Address 8. Phone No.

9. Address

Permanent

Temporary

hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mentionow receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death

PART A (EPF)

Name of the

minee/nominee's

Address Nominee's

relationship withthe member

Date Of

Birth

Total Amount or

Share ofaccumulation inProvident Fund

to be paid toeach nominee

If the nominee is minor

,name & relationship &address of the guardianwho may receive theamount during the

NOMINATION AND DECLARATION FORM

NO.66, 3RD MAIN ROAD,,SHANMUGA SUNDHARAR NAGAR,MADHAVARAM,CHENNAI,TAMILNADU,600060

NO.66, 3RD MAIN ROAD,,SHANMUGA SUNDHARAR NAGAR,MADHAVARAM,CHENNAI,TAMILNADU,600060

CB/CBE/0087722/000/0000010

FORM 2 (Revised)

AJAY KUMAR SINGH

05-Jan-1986

MARRIED

UMROA SINGH

MALE

91

,,,,,

NO.66, 3RD MAIN

ROAD,,SHANMUGASUNDHARAR

NAGAR,MADHAVARAM,CHENNAI,TAMILNADU,600060

16-Jul-1987 100NKI SINGH WIFE

Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 andhould I acquire a familly hereafter the above nomination should be deemed as cancelled.

strike out whichever is not applicable Signature or thumb impression of the Subscriber

Certified that my father / mother is / are dependent upon me.

7/28/2019 Ajay Kumar Singh - Pf No.10

2/2

PART B (EPS)(Para 18)

I hereby furnish below particulars of the members of my family who would be eligible receivewidow/children pension in the event of my death

Sl.No

1.

Name and Address of the family member Date Of Birth

4

Relationship withmember

5Address

3Name

2

NO.66, 3RD MAINROAD,,MADHAVARAM,CHENNAI,TAMIL

1 RINKI SINGH 16-Jul-1987 WIFE

NO.66, 3RD MAIN

ROAD,,MADHAVARAM,CHENNAI,,6000

2 PURNIMA SINGH 05-May-2003 DAUGHTER

NO.66, 3RD MAIN

ROAD,,MADHAVARAM,CHENNAI,,6000

3 TUSKAR SINGH 04-Aug-2005 SON

I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in theevent of my death wihout leaving any eligible family member for receiving pension

**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire afamily hereafter I shall furnish particulars thereon in above form.

Relationship with the memberDate Of BirthName and Address of Nominee

Name and address of the Factory/Establishment or rubber stamp thereof

Designation

Signature of the employer or the otherauthorized Officers of the establishment

lace :

ate :

Certified that the above declaration and nomination has been signed/ thumb impressed before me byhri/Smt/Kum employed in my establishment after he/she has read the entries/entries haveeen read over to him/her by me and got confirmed by him/her.

CERTIFICATE BY EMPLOYER

Signature or thumb impression of the Subscriberstrike out whichever is not applicable

Date :