FORM - 2 ( Revised)
NOMINATION AND DECLARATION FORM
FOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS
Declaration and Nomination Form Under the Employee's Provident Funds & Employees' Pension Scheme
(Paragraph 33 & 61 (1) of the Employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employees's Pension Scheme, 1995)
1 Name (In Block Letters) : HARDIK .
2 Father's / Husband's Name : KANWARPAL
3 Date of Birth : 03-02-2000
4 Sex : Male
5 Marital Status : Unmarried
6 Account Number : 41791438470
7 Address
A) Permanent
KANWARPAL,HOUSE 63M,GALI NO 5 TULSI NAGAR,KUKRA KUKARA,MUZAFFARN
AGAR,Uttar Pradesh (UP),251001,India
B) Temporary
63 M,gali N. 5,tulsi Nagar,muzaffarnagar,muzaffarnagar,uttar Pradesh (up),251001,in
dia
8 Date of Joining EPF : 20-10-2025
:
EPS :
PART - A (EPF)
I here by nominate the person(s) / cancel the nomination made by me previously and person(s) mentioned below to receive
the amount standing to my credit in the Employees' Provident Fund, in the event of my death.
Name & Address of the Nominee's relationship Date of Total amount of share of if the nominee is minor name &
Nominee/ Nominees with the member Birth accumulation in provident address & relationship of the
fund to be paid to each nominee guardian who may receive the amount
1 2 3 4 5
Savita Devi, 63 M Gali N. Mother 10-05- 100 ,,
5 TULSI NAGAR 1977
Muzaffarnagar
Muzaffarnagar Uttar
Pradesh (UP) India
251001
1 Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme 1952 and should I
2 Certified that my father / mother is / are depended upon me.
3 Unmarried members in the absence of dependent parents may nominate any other person to receive the shares
Note: A Fresh nomination shall be made by the member on
Signed on: 30-09-2025 11:37
his/her marriage and any nomination made before such Signature or thumb impression of the Subscriber
marriage shall be deemed to be invalid
PART - B (EPS)
I here by furnish below particulars of the members of my family who would be eligible to receive widow/children pension in the event of my death
[Link] Name of the Family Members Address Date of Birth Relationship
1 Savita Devi 63 M Gali N. 5 TULSI NAGAR 10-05-1977 Mother
Muzaffarnagar Muzaffarnagar Uttar
Pradesh (UP) India 251001
Certified that I have no family as defined in para 2 (vii) of the Employee's Pension Scheme 1995 and should I acquire a
family hereafter the above nomination should be deemed as cancelled
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16(2) (g) (I) & (ii)
in the event of my death with out leaving any eligible family member for receiving pension.
Name & Address of the Nominee Date of Birth Relationship with the member
Savita Devi, 63 M Gali N. 5 TULSI NAGAR 10-05-1977 Mother
Muzaffarnagar Muzaffarnagar Uttar Pradesh
(UP) India 251001
Date : 30-09-2025 11:37
Signature / Thumb impression of the subscriber
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before shri/Smt/Kum
HARDIK . employed in my establishment after he/she has read the entry/entries have been read over to
him/her by me and got confirmed by him/her.
Place:
Date:
Signature of the employer
Name & Address of the Establishment