FORM OF NOMINATION-II

Account No. ………8336… ...… I, Anjan Kumar Banerjee hereby nominate the person(s) mentioned below who is/are member(s) /Non-member(s)
of my family [as defined in para 4(f) of the W. B. Recognized Non-Government Educational Institution Employees’ Management of General Provident
Fund Accounts) Scheme, 1995] to receive the amount that may stand to my credit in the Fund as indicated below, in the event of my death
before that amount has become payable or having become payable has not been paid.

Name, address & relationship

Contingencies on
of the persons, if any, to If the nominee is not a
Relationship Age of the happening of
Name & Full address of Share payable to whom the right of nominee member of the family as
with the the which the
the nominee(s) each nominee(s) shall pass in the event of provided in Para 4(f)
subscriber nominees nomination will
his/her predeceasing the indicate thereasons
become invalid
subscriber
(1) (2) (3) (4) (5) (6) (7)

RANJITA BANERJEE ARITRA BANERJEE (SON)

BHATTACHARYA (WIFE) In the event of Abhinandan Pally, Bharsala Para,
WIFE 29 YEARS FULL NA
Abhinandan Pally, Bharsala Para, DIVORCE or INSANITY Rampurhat, P.O- Rampurhat,
Rampurhat, P.O- Rampurhat, Birbhum Birbhum

Dated this ...25th.... day of...May... 2022 ............ at Nowapara High School
Two witnesses to signature:
Name & Address Signature

(1) Bikash Kumar Laha, Bujung, Birbhum …………………………………………………………. Signature of the Subscriber: ....................................................

(2) Ujjwal Kumar Mondal, Nalhati, Birbhum ………………………………………………………… Name in Block Letters: ANJAN KUMAR BANERJEE

Designation: Assistant Teacher

Space for use by the Head of Office

Nomination by Sri/Smt/Kumari, Anjan Kumar Banerjee Designation: Asst. Teacher Signature of Head of Institution: …………………………………….
Designation: Teacher-in-Charge, Nowapara High School
Date of receipt of nomination: …………………………
Instruction for the subscribers:

(a) Your name may be filled in.

(b) Name of the fund may be completed suitably.
(c) Definition of term ‘family’, as given in the para 4(f) of the Scheme, is reproduced below:

Family means:

(i) In the case of a male subscriber, the wife or wives and children of a subscriber and the widow or widows, children of a deceased son of the subscriber. Provided
that, if a subscriber proves that his wife has been judicially separate from him or has ceased under the customary law of the community to which she belongs to be
entitled to maintenance, she shall thenceforth be deemed to be no longer a member of the subscriber’s family in matters to which this scheme relates, unless the
subscriber subsequently indicates by express notification in writing to the Accounts Officer that she shall continue to be so regarded;

(ii) In thecaseofafemalesubscriber, thehusbandandchildrenofasubscriber, andthewidoworwidowsandchildren of adeceasedsonof asubscriber:Provided that

if a subscriber by notification in writing to the Accounts Officer expresses her desire to exclude her husband from her family, the husband shall thenceforth be deemed
to be no longer a member of the subscriber’s family in matters to which this scheme relates, unless the subscriber subsequently cancels formally in writing her
notification excluding him.

Note: 1. — “Children means legitimate children”.

2. —Anadopted childshall be considered to bechildwhen theHeadoftheInstitution, of ifanydoubt arises inthe mindoftheHeadof the Institution,the Government
is satisfied that under the personal law of thesubscriber, adoption is legallyrecognized as conferring thestatus of a natural child, but in this case only.

(d) Col. 4— If only one person is nominated the words 'in full’ should be written against the nominee. If more than one person is nominated, the share payable to
each nominee over the whole amount of the Provident Fund shall be specified.

(e) Col. 5— Death of nominee(s) should not be mentioned as contingency in this column may be filled in with the words in the event of divorce or insanity.

(f) Col. 6— Do not mention yourname.

(g) Draw a line across the blank space below last entry to prevent insertion of any name after you have signed.

Note: A nomination shall become invalid in case a subscriber, who had no family at the time of nomination, subsequently acquires a family.
 FORM – III

INDEX REGISTER

Name of the Name of father / Date of Date of Account Month and year Ledger Details of Details of
subscriber husband of the birth appointment Number for which Folio No. nomination reasons for
subscriber allotted deduction closure of
towards GPF account
started
(1) (2) (3) (4) (5) (6) (7) (8) (9)

RANJITA BANERJEE
BHATTACHARYA,
(WIFE)
ANJAN KUMAR AMAL KUMAR 01-03-1986 01-12-2010 8336
BANERJEE BANERJEE FULL SHARE
Address
Abhinandan Pally,
Bharsala Para,
Rampurhat, P.O-
Rampurhat, Birbhum