form 2 - pf nomination
Post on 18-Apr-2015
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KN/BN/16759/
For Unexempted/ Exempted Establishment (Revised)
1. : 7. Account No :
2. : 8. Address :
: Permanent :
3. :
4. Sex : Male Female Temporary :
5. Marital Status :
*
*
Strike out whichever is not applicable.
(Paragraph 33 & 61 (1) of the Emploees' Provident Fund Scheme, 1952 & Paragraph 13of the Employees' Pension Schemes, 1995)
Signature or thump impression of the subscriber.
Certified that I have no family as defined in part 1 (g) of the Employees Provident Fund Scheme, 1952 and sholud I
Address
Nominee's
relationship
with member
Date of Birth
Part - A (EPF)
KN/BN/16759/
FORM
Name
Father's Name
Date of Birth
Husband's Name
Declaration and Nomination Form under the Employees Provident Fund & Employees' Pension Schemes
Employees' Provident Fund Organisation
Nomination and declaration Form
2
I hereby nominate the person (s) / cancel the nomination made by me previously and nominate the person (s) mentioned
Share of
accumulation in
Provident Fund to be
paid to each
nominee
if the nominee is a minor name
& address of the guardian who
may receive the amount during
the minority of nominee
below to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death
Name of the
Nominees
acquired a family hereafter the above nomination should be deemed as cancelled.
Certified that my Father / Mother is/are dependent upon me.
FOR OFFICE USE
*
Date :
Strike out whichever is not applicable.
Date :
For ASM Technologies Limited
Authorised Signatory
Signature of the employer or other authorised officers of the establishment
#80/2, Lusanne Court,
Richmond Road,
Bangalore - 560 025.
…..………………………………………………………………Employed in my establishment after he / she has read the entries / have
been read over to him / her by me and got confirmed by him / her.
ASM Technologies Limited
Name & Adress of the Factory / Establishment :
Signature or thump impression of the subscriber.
Certificate by Employer
I Certified that above declaration, and nomination has been signed/thumb impressed before me, by Sri / Smt. / Kum.
Name of the
NomineeAddress of the Nominee Date of Birth Relationship with member
Relationship with memberName of the
Family MemberAddress Date of Birth
acquired 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) (a)
Certified that I have no family as defined in para 2 (vii) of the Employees' Pension Scheme, 1995 and sholud I
(i) and (ii) in the event of my death without leaving any eligible family member for receiving pension.
Part - B (EPS)
I hereby furnish below particulars of the members of my family whowould be eligible to receive Widow / Children Pensionin the event of my death.
(Para - 18)
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