Professional Documents
Culture Documents
EPF Nomination Form
EPF Nomination Form
1. Name
SUPRIYA BOSE
DIPAK BOSE
3. Date Of Birth
27-Jun-1982
4. Sex
MALE
5. Marital Status
UNMARRIED
6. Account No.
WB/HLO/0036779/000/0000217
8. Phone No.
91
7. E Mail Address
9. Address
Permanent
Temporary
C/O SUDIP KUMAR MONDAL,,NISCHINDA PURBA PARA, NEAR WATER TA,,HOWRAH,WEST BENGAL,711227
C/O MANTU MALO DAS, NISCHINDA PURBA,PARA NEAR UDYAN SANGHA CLUB,,HOWRAH,WEST BENGAL,711227
PART A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
Name of the
nominee/nominee's
DIPAK BOSE
Address
Nominee's
relationship with
the member
DEPENDENT FATHER
Date Of
Birth
08-Nov-1940
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
100
,,,,,
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
* Certified that my father / mother is / are dependent upon me.
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Date Of Birth
Address
3
Relationship with
member
5
DIPAK BOSE
08-Nov-1940
FATHER
SOMA BOSE
17-Jan-1972
SISTER
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
Date Of Birth
Date :
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.
Date :
Place :