(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) : _______________________________________________________________________________

Name Father’s / Husband’s Name Surname

2. Date of Birth : ___________________ 3. Account No. ___________________

4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________

6. Address Permanent / Temporary : _____________________________________________________________________________

________________________________________________________________________________

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

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.

Strike out whichever is not applicable Signature/or thumb impression

of the subscriber

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.

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

Date ___________________

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 :
 FORM 'F'
See sub-rule (1) of Rule 6

Nomination

To,
(Give here name or description of the establishment with full address)

I, Shri/Shrimati/Kumari
(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable
after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having
become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s)
of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h) of Section 2 of the
Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.

4 (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to
the controlling authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Name in full with full Relationship with the Age of Proportion by which
address of nominee(s) employee nominee the gratuity will be
shared
(1) (2) (3) (4)
1.
2.
3.
So on.

Statement
1. Name of employee in full
2. Sex
3. Religion
4. Whether unmarried/married/widow/widower
5. Department/Branch/Section where employed
6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
8. Permanent address:
Village Thana Sub-division
 Post Office District State

Place:
Signature/Thumb-impression of the
Employee
Date:

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place:
Date:

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised
Designation

Date: Name and address of the establishment or

rubber stamp thereof.

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date: Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.

 Payment of Wages (Nomination) Rules, 2009
FORM – I
Nomination and Declaration Form
(See Rule 3)
1. Name of Person making nomination
(in block letters)
2. Father’s/Husband’s name
3. Date of Birth
4. Sex
5. Marital Status
6. Address
Permanent
Temporary

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the
person(s) mentioned below to receive any amount due to me from the employer, in the event of my
death.

Name of Address Nominee’s Date of Total amount of If the nominee is

Nominee/ relationship Birth share of a minor, name
nominees with the accumulations and address of
member in credit to be the guardian
paid to each who may receive
nominee the amount
during the
minority of the
nominee
1 2 3 4 5 6

1. Certified that I have no family and should I acquire a family hereafter, the above
nomination shall be deemed as cancelled.
2. *Certified that my father/mother is/are dependent on me.
3. *Strike out whichever is not applicable.

Signature or thumb impression

of the employed person
 CERTIFIED 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 has read the entry/entries have been read over
to him/her by me and got confirmed by him/her.

Signature of the employer or other authorised

Officer of the establishment and
Designation

Place:
Date:

Name and Address of the Factory/

Establishment and rubber stamp thereof