(FORM 2 REVISED)
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)
1. Name (IN BLOCK LETTERS) : _Saurabh______________Rakesh________________Mohapatra
Name Father’s / Husband’s Name Surname
2. Date of Birth : ___12/ Nov /1982 (DD/MM/YYYY)_____ 3. Account No. ___________________ Leave it Blank
4. *Sex : MALE/FEMALE: _____Male______ 5. Marital Status __________Single__________________
6. Address Permanent / Temporary : H. No. 124, Raj Hans Appartment, Sector – 62, Noida,
U.P. - 201301_________________________________
PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below
to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee
1 2 3 4 5 6
H. No. 124, Raj Hans
Appartment, Sector – 62,
Sushma Mohapatra Noida, U.P. - 201301 Mother 15/ Mar /1956 50%
H. No. 124, Raj Hans
Appartment, Sector – 62,
Rakesh Mohapatra Noida, U.P. - 201301 Father 01/ Jan /1952 50%
1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund 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.
SIGN HERE
Strike out whichever is not applicable Signature/or thumb impression
of the subscriber
Married people fill your Spouse & Kids details here
PART – (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 my premature death in service.
Sr. No Name & Address of the Family Member Age Relationship with the member
(1) (2) (3) (4)
Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a family
hereafter I shall furnish Particulars there on in the above form.
Unmarried people fill your parent’s details here
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the event
of my death without leaving any eligible family member for receiving pension.
Name and Address of Date of Birth Relationship with member
the nominee
Sushma Mohapatra
15/ Mar /1956
H. No. 124, Raj Hans Appartment, Sector
– 62 Mother
Rakesh Mohapatra
01/ Jan /1952 Father
H. No. 124, Raj Hans Appartment, Sector
– 62
Date ___01/ July /2015___
SIGN HERE
Signature or thumb impression
of the subscriber
____________________________________________________________________________________________________________
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./
Miss_________________________________________________________________ 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.
Date : _____________________ Signature of the employer or other authorised officer of the
establishment
Place :
Name & address of the Factory /Establishment
Date :