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    Nomination and Declaration Form

    Uploaded by

    Sanjay Tyagi
    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It collects information such as the employee's name, father/husband's name, date of birth, sex, marital status, and account number. It then has the employee nominate individuals to receive the funds in their account in the event of death. Sections are included to provide details of family members eligible for widow/children's pension. The employer must sign to certify that the employee completed or had the form read to them.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Nomination and Declaration Form

    Uploaded by

    Sanjay Tyagi
    42 views3 pages
    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It collects information such as the employee's name, father/husband's name, date of birth, sex, marital status, and account number. It then has the employee nominate individuals to receive the funds in their account in the event of death. Sections are included to provide details of family members eligible for widow/children's pension. The employer must sign to certify that the employee completed or had the form read to them.

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    nomination

    Original Title

    nomination

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    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It collects information such as the employee's name, father/husband's name, date of birth, sex, marital status, and account number. It then has the employee nominate individuals to receive the funds in their account in the event of death. Sections are included to provide details of family members eligible for widow/children's pension. The employer must sign to certify that the employee completed or had the form read to them.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    42 views3 pages

    Nomination and Declaration Form

    Uploaded by

    Sanjay Tyagi
    This document is a nomination and declaration form for an employee's provident fund and pension scheme. It collects information such as the employee's name, father/husband's name, date of birth, sex, marital status, and account number. It then has the employee nominate individuals to receive the funds in their account in the event of death. Sections are included to provide details of family members eligible for widow/children's pension. The employer must sign to certify that the employee completed or had the form read to them.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    Employee No_______________

    NOMINATION AND DECLARATION FORM


    (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)

    2 Father’s/Husband’s Name

    3 Date of birth

    4 Sex

    5 Marital Status

    6 Account No. (PF/EPS Number)

    Permanent

    7 Address (Residential)

    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:

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

    PF Nomination Form.doc
    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.
    (Strike out whichever is not applicable).

    ----------------------------------------------------------------------
    Signature or thumb impression of the subscriber

    Note: - A Fresh nomination shall be made by the member on his marriage and any nomination made before such marriage shall be deemed
    to be invalid

    Part B (EPS)
    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 and address of the family members Date of Birth of Relationship with
    the nominee the member

    (1) (2) (3) (4)


    1

    4
    PF Nomination Form.doc
    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) of
    Employees’ Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving Pension.

    Name and Address of the Nominee Date of Birth of the Relationship with the member
    nominee

    (1) (2) (3)


    ONLYSPOUSEDETAILS

    Date ______________
    ………………………………………
    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
    or rubber stamp thereof

    PF Nomination Form.doc

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