Employee No.
9094691
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 & 61 (1) of the Employees’ Provident Funds Scheme, 1952 and paragraph 18 of the Employees’ Pension Scheme, 1995)
1 Name (in Block Letters) : Vishesh Jaiswal
2 Father’s/Husband’s Name : OM PRAKASH JAISWAL
3 Date of Birth : 16/08/1994
4 Sex (Male/Female) : Male
5 Marital Status : Single
6 Account No. (PF/EPS Number) : NA
7 Address (Residential) : Permanent: Ward no 22 bouri para ambikapur surguja chhattisgarh
9826171914
Temporary: Ward no 22 bouri para ambikapur surguja chhattisgarh
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:
Name of Address Nominee’s relation- Date of Total amount of Share of If the nominee is a minor,
nominee/ ship with the member Birth Accumulations in Provi- name & relationship & address
Nominees dent Fund to be paid to of the guardian who may
Each nominee receive the amount during
The minority of nominee
1 2 3 4 5 6
Om prakash Ward no 22 Father 15 Jan 1966 50
jaiswal bouri para
ambikapur
surguja
chhattisgarh
Rita jaiswal Mother 12 June 1977 50
1 * Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds 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.
3. * Strike out whichever is not applicable.
< Employee Signature >
Signature or thumb impression of the subscriber
**Strike out whichever is not applicable.
Part B (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 death.
Sl. No. Name of the family Address Date of Birth Relationship with the member
member
1 2 3 4 5
** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in the above form.
I hereby nominate the following persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii) in
the event of my death without leaving any eligible family member for receiving Pension.
Name and Address of the Nominee Date of Birth Relationship with the member
1 2 3
Date: 06/JAN/2021
Signature or thumb impression of the subscriber
**Strike out whichever is not applicable.
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Kumari_
__________________________________________________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.
Place: ___________________
Date __________________
Signature of the Employer or other authorised
Officer of the establishment
Designation……………………………………….
Name and address of the Factory/Establishment
