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PF Nomination Form

This document is a nomination and declaration form for the Employees' Provident Fund and Pension Scheme in India. It contains fields for the employee to provide their personal details and nominate family members to receive funds from their provident fund and pension in the event of their death. Key sections allow the employee to provide names and details of nominated provident fund and pension beneficiaries, certify their family status, and provide family member details for pension eligibility. The form must be signed by both the employee and the authorized representative of their employer.

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Narendra Gaur
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1K views3 pages

PF Nomination Form

This document is a nomination and declaration form for the Employees' Provident Fund and Pension Scheme in India. It contains fields for the employee to provide their personal details and nominate family members to receive funds from their provident fund and pension in the event of their death. Key sections allow the employee to provide names and details of nominated provident fund and pension beneficiaries, certify their family status, and provide family member details for pension eligibility. The form must be signed by both the employee and the authorized representative of their employer.

Uploaded by

Narendra Gaur
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM – 2 (REVISED)

NOMINATION & DECLARATION FORM


FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS

Declaration & Nomination Form Under the Employees’ Provident Funds & Employees Pension Scheme
Paragraph 33 & 61 (11) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’
Pension Scheme 1995

1. Name (in Block Letters)

2. Father’s / Husband’s Name

3. Date of Birth 4. Sex Male / Female

5. Marital Status

6. Account No. TN

Permanent: Temporary:
7. Address

8. Date of Joining EPF EPS

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 & Address of the Nominee’s Date of Birth Total amount or If the nominee is a
nominee / nominees relationship share of minor, name &
with the accumulations in relationship &
member Provident Fund to address of the
be paid to each guardian who may
nominee receive the amount
during the minority
of nominee
1 2 3 4 5

1. * Certified that I have no family as defined in para 2 (g) of the Employee’s Provident Fund Scheme 1952 and
should I acquire a family hereafter the above nomination should be deemed cancelled.
2. * Certified that my father / mother is / are dependent upon me
3. * Unmarried members in the absence of dependent parents may nominate any other person to receive the
shares.
* Strike out whichever is not applicable.

Note : A fresh nomination


shall be made by the member
on his marriage and any
nomination made before such ()
marriage shall be deemed to Signature / thumb impression of the subscriber
be invalid
P.T.O
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.

S No. Name of the Family Address Date of Birth Relationship with


Members the member

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

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 without leaving any eligible family member for receiving pension

Name & Address of the nominee Date of Birth Relationship with the member

Date:

()

**Strike out whichever is not applicable Signature or left 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/Kum employed in my establishment after he/she read the

entries/entries have been read over to him/her by me and got confirmed by him/her.

Place: Signature of the employer or authorized officers of the establishment

Name :

Date : Designation:

Name & Address of the factory / Establishment or Rubber Stamp thereon

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