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)