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    BPOFin Form 2

    Uploaded by

    Naveen S
    1) S Naveen has submitted a nomination and declaration form for his Employees' Provident Fund (EPF) and Pension Scheme accounts. 2) For his EPF account, he nominates his mother Devika S to receive the funds standing in his EPF account in the event of his death. 3) For his Pension Scheme account, he provides details of his mother Devika S as his only family member eligible to receive pension benefits upon his death.

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    BPOFin Form 2

    Uploaded by

    Naveen S
    12 views3 pages
    1) S Naveen has submitted a nomination and declaration form for his Employees' Provident Fund (EPF) and Pension Scheme accounts. 2) For his EPF account, he nominates his mother Devika S to receive the funds standing in his EPF account in the event of his death. 3) For his Pension Scheme account, he provides details of his mother Devika S as his only family member eligible to receive pension benefits upon his death.

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    BPOFinForm2

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    1) S Naveen has submitted a nomination and declaration form for his Employees' Provident Fund (EPF) and Pension Scheme accounts. 2) For his EPF account, he nominates his mother Devika S to receive the funds standing in his EPF account in the event of his death. 3) For his Pension Scheme account, he provides details of his mother Devika S as his only family member eligible to receive pension benefits upon his death.

    Copyright:

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

    BPOFin Form 2

    Uploaded by

    Naveen S
    1) S Naveen has submitted a nomination and declaration form for his Employees' Provident Fund (EPF) and Pension Scheme accounts. 2) For his EPF account, he nominates his mother Devika S to receive the funds standing in his EPF account in the event of his death. 3) For his Pension Scheme account, he provides details of his mother Devika S as his only family member eligible to receive pension benefits upon his death.

    Copyright:

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

    Employees’ Provident Fund Organization *Emp. No.

    _9066112_

    *Date of Joining 9/9/2022


    NOMINATION AND DECLARATION FORM FORM NO 2 (Revised)
    FOR UNEXEMPTED ESTABLISHMENTS

    Declaration and nomination form under the Employee’s Provident Funds and Employee Pension Scheme
    (Paragraph 33 & 61 of the Employee's Provident Fund Scheme, 1952 & Paragraph 18 of the Employees' Pension
    Scheme 1955)
    PART – A (EPF)

    *Name in Block Letters: S NAVEEN *Permanent Address: H.E.S Colony G-67 T.B Dam,
    Vidyut Nagar Hospet – 583225, Vijayanagara (D)
    *Father's/Husband's Name: V Sreenivasan Karnataka
    (in case of married woman)
    *Date of Birth: 21/02/1997

    *Sex (Male/Female): Male *Temporary Address: H.E.S Colony G-67 T.B Dam,
    Vidyut Nagar Hospet – 583225, Vijayanagara (D)
    *Marital Status: Unmarried Karnataka

    Account No:

    I hereby nominate the person (s) / cancel the nomination made by me previously and nominate the person(s)
    mentioned below to receive the amounts standing to my credit in the Employee’s Provident Fund in the event of
    my death

    *Total amount of If nominee is minor:


    share of Name, relationship &
    *Nominee’s
    *Name and address of accumulation in address of the guardian
    Relationship with *Date of Birth
    the Nominee/s Provident Fund to who may receive the
    the member
    be paid to each amount during the
    nominee minority of nominee

    NA

    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 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
    _____________________________________________________________________________________________

    FOR OFFICE USE ONLY

    Dt. Of Joining E.P.F. Entries verified

    Past Service _________ years


    Date of Joining EPS D.A. S.S. A.A.O

    PART - B ( EPS)Para 18

    I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/
    Widower/Children Pension in the event of my death: -

    *Name of the Family *Relationship with


    SI.No *Date of Birth *Address member
    member

    1. Devika S
    H.E.S Colony G-67 T.B Dam,
    Vidyut Nagar Hospet –
    7/06/1972 Mother
    583225, Vijayanagara (D)
    Karnataka

    ** 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 person for receiving the monthly 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 member

    *Date: 9/9/2022

    *Strike out whichever is not applicable *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/ Kum.……………………………………………………………………………………………………………………employed
    in my establishment after he/she has read the entries/entries have been read over to him/her by
    me and got confirmed by him/her.

    Signature of the Employer or other authorised Officers of the establishment

    Designation

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