FORM -2( Revised) (=) NOMINATION AND DECLARATION FORM FOR EXEMPTED / UNEXEMPTED ESTABLISHMENTS, Declaration and Nomination Form Une the Employ Provident Fan &Enplayces Pace Shh a, _SHRADDHA SAHA 2 Fathers Husunds Name _MRINALESH —s 3 Date of Birth el 4 Sex eee ee 5 Marital Status _ Unmarried —s 6 Account Number 7 Address Permanent Plot No 52/9, Maityi Vihav, Kohka Bhilai, 440023 ‘Temporary 2 as 8 Date of Joining, 4-09-2020 _| EDF eee eae EPS 2a PART-A (EPR) I here by nominate the person(s) / cancel the nomination made by me previously anel person(s) mentioned below to receive the amount standing to my credit in the Employees’ Provident Fund, in the event of my death, Name & Address ofthe | Nominees relationship | Date of Tot int of share of Ifthe nominee i minor name & oe eeeme |e) emcee | | eee tadotepsiwech mine | guint ny eee oon ; 3 3 : " : al [xg _ RIAU rarer |S PLOT No-S2/A 1072, louthyi Vy heer, e = a a ohKa = 490023 Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme 1952 ard shoul 41 acquire a family hereafter the above nomination should be deemed as cancelled 2. Certified that my father / mother is / are depended upon me. 3. Unmarried members in the absence of dependent parents may nominate any other person to ‘Note: A Fresh nomination shall be made by the member on his/her marriage and any nomination made before such, marriage shall be deemed to-be invalidPART-B (EPS) Thereby furnish below particulars of the members of my family who would be eligible to receive widow children pension fn the event of my death Date of Bieth] Relationship FAY S.No] Name of the Family Members Address a] MRTNA LESH SAHA|Plot No 52)A, Marti Vihar 4- 0: 2 RANTU SAHA [Plot No 52) A,MaihiVihod lO - 03-1974 MOTHER 3| SHREYA SAHA |P lot Mos2jA, Mahi Vint 4-05-2005 SISTER 4 oa al Certified that I have no family as defined in para 2 (vi) of the Employee's Pension Scheme 1995 and should I acquire family hereafter the above nomination should be deemed as cancelled Thereby nominate the following person for receiving the monthly widow pension (admissible under para 16(2) (g) (1) & (i) in the event of my death with out leaving any eligible family member for receiving, pension. [ [Name & Address ofthe Nominee Date of Birth Relationship withthe member] MRINALESH SAHRA & PloT| 14-08-4992 | FATHER. No 52] A, Matitei Vihoer, kohke hited a = 49 0025 _ \ Dae: J4- D9- 2020 , Pelee Signature / Thumb impression of the subscriber (CERTIFICATE BY EMPLOYER \Cettified that the above declaration and nomination has been signed/thumb impressed before shri/Smt/Kum «..c.. ———— employed in my establishment after he/she has read the entry /entries have been read oves to lhim/her by me and got confirmed by him/her. Place: [Date = Signature of He employer [Name & Address ofthe Establishvaent