Employee No.

Form-I
(Mandatory)
NOMINATION AND DECLARATION FORM
[See Rule 3]

1. Name of person making nomination (in block letters) CHAITANYA LAKSHMI VALLAPUNENI

2. Father’s/Husband’s Name

3. Date of Birth 14-Aug-91

4. Sex Female

5. Marital Status Married

6. Address:

Permanent Flat No.303,Maruthi Pride,Aleap Circle Opposite to sai baskar hub building Hyderabad

Present Flat No.303, Maruthi Pride, Pragathi Nagar, Hyderabad

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned
below to receive any amount due to me from the employer, in the event of my death.

Total amount If the nominee is

of share of minor,name,realtionship
accumulations and address of guardian
Nominee's in credit to be who may receive the
Name of the relationship with paid to each amount during the minority
nominee/ nominees Address the member Date of Birth nominee of nominee
(1) (2) (3) (4) (5) (6)
Venkata FA 01-Jun- 40.00
apparao 66
Vallapuneni

Vamshi HU 22- 30.00

Krishna Mar-89
Mallela

Nilavathi MO 01-Jun- 30.00

Vallapuneni 58

< Total % of share should be 100% >

1. Certified that I have no family and should I acquire a family hereafter, the above nomination shall be deemed as
cancelled.
2. Certified that my *father/mother is/are dependent upon me.

*Strike out whichever is not applicable < Employee Signature >

Signature or the thumb impression of
the employed person.
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 entry/entries
have been read over to him/her by me and got confirmed by him/her.

Signature of the employer or other authorized

Officer of the establishment and Designation

Place _________________
Date _________________ Infosys Limited,
No.44, Electronics city,
Hosur Road,
Bangalore- 560 100