EMP CODE: 111018740

DOJ: 28-Apr-2023

FORM NO.2 (Revised) UAN Number:

NOMINATION AND DECLARATION FORM
FOR UNEXEMPTED/EXEMPTED ESTABLISHMENT
Declaration and Nomination for under the Employee's Provident Funds and Employee's Pension Schemes
(Paragraph 33 and 61 (1) of the Employee's Provident Fund Scheme 1952 & Paragraph 13 of the Employee's Pension Scheme, 1955)

1. Name (In block letters) MUSKAN 6. Account No. GJ/AHD/28449/

GR. No. XVIII

2. Father's/Husband's Name RAJESH DAVID 7. Date of Joining in E.P.F. 52 28-Apr-2023

3. Date of Birth 29-Jun-2000 8. Date of Joining in F.P.F. 70 / 28-Apr-2023

E. P. S. 95

4. Sex Female Permanent Address : 183/11a Shanti Nagar, Near Hanuman Park, Hisar, Haryana -
125001

5. Marital Status Unmarried Temporary Address : 183/11a Shanti Nagar, Near Hanuman Park, Hisar, Haryana -
125001

PART - A (E.P.F.)
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 Employee's Provident Fund, in the event of my death.
Total amount If the nominee is a
of share of minor, name
Nominee's accumulation and address of the
Name of the Date Of Birth &
Address relationship with the in Provident guardian who may
Nominee/Nominees Age of Nominee(s)
member Fund to be receive the amount
paid to each during the minority of
nominee the nominee
1 2 3 4 5 6

MANISHA DAVID 183/11a Shanti Nagar, Near Mother 29-Nov-1976 100% NIL
Hanuman Park, Hisar, Haryana - 47
125001

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 canelled.

2. * Certified that my father/mother is/are depeneded upon me.

* Strike out whichever is not applicable Signature or thumb impression of the subscriber
 PART - B (E.P.S.) (PARA - 18)
I hereby furnished below particulars of the members of my family who would be eligible to receive widow / children pension in the event of my death.

Serial Relationship with the

Name of the family member Address Date Of Birth & Age of Nominee(s)
No. member
1 2 3 4 5

1 RAJESH DAVID 183/11a Shanti Nagar, Near Hanuman Park, Hisar, Haryana - 01-Jan-1973 Father
125001 50
2 MANISHA DAVID 29-Nov-1976 Mother
47

** Certified that I have no family as defined in para 2(b) of the Employee's 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 widow pension (admissible under para 16 2 (a) (I) & (ii) in the event of the death without
leaving any eligible family member for receiving pension.

Name & Address of the Nominee Date of Birth Relationship with member
MANISHA DAVID 29-Nov-1976 Mother
183/11a Shanti Nagar, Near Hanuman Park, Hisar, Haryana - 125001 47

Date : 28-Apr-2023
* Strike out whichever is not applicable Signature of thumb impression of the Subscriber

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thump impressed before me by Shri/Smt.Kum.__MUSKAN___ employed in my
establishment after he/she has the entries/the entries have been read over to him/her by me and got confirmed by him/her.

TTEC INDIA CUSTOMER SOLUTIONS PVT. LTD.

For, TTEC INDIA CUSTOMER SOLUTIONS PVT. LTD.
(Formerly Motif India Infotech Pvt. Ltd.)
(Formerly Motif India Infotech Pvt. Ltd.)
TTEC Ahmedabad, Opp. L.J. College,
Off. S G Road, Makarba,
Ahmedabad- 382210,
Gujarat, India. Phone: 26569828
BADAL PALKHIWALA
Place: Ahmedabad SENIOR MANAGER, TALENT ACQUISITION
Date: 28-Apr-2023
Signature of the Employer/Authorised officer.
Name and address of the establishment Or rubber stamp thereof