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IND Statutory forms- Guidelines & Sample Form

CHECKPOINTS to avoid rework:

 Hand filled forms are not accepted
 Fill the forms digitally & submit self-attested forms (printed copies) to People Services
 Mark signatures wherever required
 Cross check details filled with the sample form
 ESIC: To be filled only if your gross salary is less than or equal to 21000 INR

While filling ESIC (Form-1), take the following into consideration-

Check points Action particulars

Father’s income is more DO NOT add details in row (D)- Family Particulars of Insured Person
than INR 5000/month

Father’s income is less Submit Certificate of Income & add details of Family members in row (D)- Family
than INR 5000/month Particulars of Insured Person
 Employees Provident Fund Scheme
FORM – 2
(Paragraph 33 & 61(1) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’
Pension Scheme, 1995)
Nomination and Declaration Form For Unexempted/
Exempted Establishment
Declaration and Nomination Form under the Employees’ Provident Funds & Employees’ Pension scheme

1. Name (in block letters):____EMP full name in Block letters as per Aadhaar ____________________________
2. Father's / Husband's Name: __EMP Father’s Name or Spouse’s Name_________________________________
3. Date of Birth (DD/MMM/YYYY): __EMP DOB as per Aadhaar________________________________________
4. Sex: ___EMP Gender________________________________________________________________________
5. Marital Status: ___EMP Marital status__________________________________________________________
6. Account No: ____Leave it Blank_______________________________________________________________
7. Address: Permanent: ___EMP permanent address in detail with pin code______________________________
Address: Temporary: ___EMP present address in detail with pin code________________________________
8. (A) Date of Joining in E.P.F Scheme, 1952______Date of Joining at S&P Global__________________________
(B) Date of Joining in E.P.F Scheme, 1971_______________________________________________________
(C) Date of Joining in E.P.F Scheme, 1995_________________________________________________________
PART-A EPF
I hereby nominate the Person(s)/Cancel the Nomination made by me previously & Nominate the Person(s),
mentioned below to receive the amount standing to my Credit in the Employees’ Provident Fund, in the event of
my Death.

Total amount or
"Date of If the Nominee is a minor, name
Nominee’s share of
Birth & relationship & Address of the
relationship accumulation in
Name of Nominee Address (dd- guardian who may receive the
with the Provident Fund
mmm- amount during the minority of
Member to be paid to
yyyy)" Nominee
each Nominee

1 2 3 4 5 6

Nominee could be Spouse/Father/Mother/Sibling. Based on the selection, please fill in the details

Relationship
Nominee’s
Nominee’s Name Nominee’s Address with Percentage Leave it Blank
DOB
Nominee

If nominating 1
person- 100%. If
two then 50%
each or the
desired share of
%
1 *Certified that I have no Family as defined in para 2(g) of the Employees’ Provident Fund Scheme, 1952 and
should I acquire a family hereafter the above Nomination should be deemed as cancelled.
2 *Certified that my Father/Mother is/are dependent upon me.

X EMP Signature required

* Strike out whichever is not applicable Signature or Thumb Impression of the Subscriber

PART – B (EPS) Para 18

I hereby furnish below Particulars of the Members of my Family who would be eligible to receive Widow /
Children Pension in the event of my Death.
Name and Address of the Family Date of Birth & Age Relationship with Member
Member
Sr.
No Name Address
1 2 3 4 5
1 Nominee Name Nominee Address Nominee DOB & Age Relationship with Nominee
2
3
4
* Certified that I have no family, as defined in para 2 (vii) of Employees’ Pension Scheme, 1995 and should I acquire
a Family hereafter I shall furnish Particulars thereon in the above Form.

Dated__DOJ at S&P____________ X EMP Signature required

* Strike out whichever is not applicable Signature or Thumb Impression of the Subscriber

CERTIFICATE BY EMPLOYER

Certified that the above Declaration and Nomination has been Signed/Impressed before me by Shri/Smt./
Km________________________________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.

Signature of the Employer or other Authorized

Officers of the Establishment Designation

Place: Designation

Date: Name & Address of the Factory /

Establishment Rubber stamp thereof.
 Composite Declaration Form -11
(To be retained by the employer for future reference)
EMPLOYEES’ PROVIDENT FUND ORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
Declaration by a person taking up employment in any establishment on which EPF scheme. 1952 and /or EPS, 1995 is applicable)

1 Name of the member EMP full name in block letters

Father’s Name
2 Father’s/Spouse’s name
Spouse’s Name
3 Date of Birth (DD/MM/YYYY) EMP DOB basis Aadhaar
4 Gender: ( Male/Female/Transgender ) EMP Gender
5 Marital Status (Married/Unmarried/Widow/Widower/Divorcee) EMP Marital status
(a) Email ID: EMP personal email ID
6
(b) Mobile No: EMP mobile number (+91 followed by 10 digits)
Present Employment Details:
7 DOJ at S&P Global
Date of joining current establishment (DD/MM/YYYY)
KYC Details: (attach Self attested copies of following KYCs)
a) Bank Account No.
Leave it Blank
8 b) IFSC code
c) AADHAR Number (12 Digit) EMP Aadhaar number
d) Permanent Account Number (PAN), If available EMP PAN number
9 Whether earlier a member of Employees ‘provident Fund Scheme, 1952 Yes No Check & put Yes/No
10 Whether earlier a member of Employees ‘Pension Scheme, 1995 Yes No as applicable
Previous employment details: [if Yes to 9 AND/OR 10 above)- Un-exempted
Date of joining Date of exit Scheme Non
Establishment Universal PF Account (DD/MM/ (DD/MM/ Certificate PPO Number Contributory
Name & Account
11 Number No. (if (if issued) Period
Address Number YYYY) YYYY)
issued (NCP) Days

Mention previous employment details, if un-exempted trust

Previous employment details: [if Yes to 9 AND/OR 10 above)- For Exempted Trusts
Scheme Non
Name & Date of joining Date of exit
Member EPS Certificate Contributory
Address of the UAN (DD/MM/ (DD/MM/
A/c Number No. (if Period (NCP)
Trust YYYY) YYYY)
issued Days
12
Mention previous employment details, for exempted trusts.
If they have own trusts.

a) International Worker: Yes No Check Yes/No as

13 b) If Yes, State Country Of Origin (India /Name of Other Country) If yes, provide the details applicable
c) Passport No. If yes, provide the details
d) Validity Of Passport (DD/MM/YYY) to (DD/MM/YYY) If yes, provide the details

UNDERTAKING

1) Certified that the Particulars are true to the best of my Knowledge

2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present P.F. account as
I am an Aadhar verified employee in my previous PF Account
4) In case of changes in above details, the same will be intimated to employer at the earliest

Date: DOJ X EMP Signature required

Place: City of Employment Signature of Member
 DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs …………………………………………………... has joined on …………………….…. and has been allotted PF Number
………………………………. & UAN ……………………………….
B. In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995
 Pease tick the Appropriate Option:
The KYC details of the above member in the UAN database
Have not been uploaded
Have been uploaded but not approved
Have been uploaded and approved with DSC/e-sign

C. In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:
 Please Tick the Appropriate Option:
The KYC details of the above member in the UAN database have been approved with e-sign/Digital Signature Certificate and transfer
request has been generated on portal
The previous Account of the member is not Aadhaar verified and hence physical transfer form shall be initiated

Date: Signature of Employer With seal of Establishment

Auto transfer of previous PF account would be possible in respect of Aadhaar verified employees only. Other employees are requested to file physical
claim.
(Form-13) for transfer of account from the previous establishment.
 Payment of Gratuity (Central) Rules
FORM 'F'
See sub-rule (1) of Rule 6
Nomination

To,
(Give here name or description of the establishment with full address)
Leave it Blank

I, Shri/Shrimati/Kumari EMP Full name in block letters

(Name in full here)
Whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive
the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that
amount has become payable, or having become payable has not been paid and direct that the said amount of
gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause (h)
of Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.
(a) My father/mother/parents is/are not dependent on me.
(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the ____________ to the controlling authority
in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.
Nominee(s)
Name in full with full Relationship with Age of Proportion by which
address of nominee(s) the employee nominee the gratuity will be shared
(1) (2) (3) (4)
1. Name of the nominee with full Spouse/Father/Mot Nominee’s If nominating just one person
address her/Sibling DOB & Age then 100%, If nominating 2
2. people then 50% each, if 3
people then 33.33% each
3.

Statement
1. Name of employee in full ____ EMP Full Name as per Aadhaar______________________________
2. Sex ___ EMP Gender________________________________________________________________
3. Religion __________________________________________________________________________
4. Whether unmarried/married/widow/widower ___EMP Marital status________________________
5. Department/Branch/Section where employed ____ Leave it Blank ___________________________
6. Post held with Ticket No. or Serial No., if any __ Leave it Blank ______________________________
7. Date of appointment ___DOJ_________________________________________________________
8. Permanent address_____EMP permanent address________________________________________
Village_________ _ Thana __________ _ Sub-division ___________Post Office _______________
District ______________ State _____________
X EMP Signature required
Place: City of Employment Signature/Thumb-impression of the
Date: DOJ Employee
 Declaration by Witnesses
Nomination signed/thumb-impressed before me
Name in full and full address of witnesses. Signature of Witnesses.
1. Witnesses Name, Address & Signatures from any two members 1.
(Friends/Colleagues/Family)

2.
2.

Place: City of Employment

Date: DOJ

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any _____________ Signature of the employer/Officer authorized
Designation

Date: Name and address of the establishment or rubber stamp thereof.

_______________________________
_______________________________

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.
X EMP Signature required
Date: DOJ Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.

 Payment of Wages (Nomination) Rules, 2009
FORM – I Nomination and Declaration Form
(See Rule 3)
1. Name of Person making nomination (in : __EMP full name as per Aadhaar_______________________________
block letters)
2. Father’s / Husband’s name : __Father’s or Spouse’s name__________________________________

3. Date of Birth : __EMP DOB________________________________________________

4. Sex : __Gender__________________________________________________

5. Marital Status : __EMP Marital status________________________________________

6. Address : __EMP present address with pin code___________________________

Present:
__________________________________________________________

__EMP permanent address in details with pin code_________________

Permanent
__________________________________________________________

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

Name of Address Nominee’s Date of Total amount of share of If the nominee is a minor, name
Nominee/ relationship Birth accumulations in credit to and address of the guardian who
nominees with the be paid to each nominee may receive the amount during
member the minority of the nominee
1 2 3 4 5 6

Name of the
Parents/Sp % of
nominee Nominee Nomine
ouse/Childr As applicable As applicable
address/Same as e DOB
en share
permanent

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 on me.
3. *Strike out whichever is not applicable.
X EMP Signature required
Signature or thumb impression of
the employed person

CERTIFIED 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.

Place: Signature of the employer or other authorized

Date: Officer of the establishment and Designation

Name and Address of the Factory/

Establishment and rubber stamp thereof
 EMPLOYEES’ STATE INSURANCE CORPORATION
Form- 1
To be filled in by the employee after reading instructions overleaf. Two Postcard Size photographs are to be
attached with this form. This form is free of cost.

(A) INSURED PERSON’S PARTICULARS (B) EMPLOYER’S PARTICULARS (Leave it Blank)

1. Insurance No. 9. Employer’s Code

No.
2. Name EMP name Day Month Year
(in block letters) 10. Date of
Appointment
3. Father’s/Husband’s EMP father’s/spouse’s name
Name 11. Name & Address of the Employer
4.Date of Birth D M Y 5.Marital M/U
Status /W
EMP DOB 6. Sex M/F 12. In case of any previous employment please fill up
the details as under:-
7. Present Address 8. Permanent Address
a) Previous Ins.No.
EMP address EMP address____________
b) Emplr’s Code No.
C) Name & address of the Employer
Pin Code …………………………… Pin Code ……………………………
Mobile number- Please mention E-mail address- Please
mention
Branch Office Dispensary
E-mail address

(C) Details of Nominee u/s 71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules, 1950 for payment of cash benefit in the event of death

Name Relationship Address

Relationship
Nominee Name Nominee’s address
with Nominee

I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the
Corporation any changes in the membership of my family within 15 days of such change.

X EMP Signature required

Counter signature by the employer Signature/T.I.of IP
Signature with Seal

(D) FAMILY PARTICULARS OF INSURED PERSON (Please refer to check points on page 1)

Sl. Name Date of Birth/ Age Relationship with Whether If’No’, state place of
No. as on date of the Employee residing with Residence
filling form Him/her?
Yes No Town State
1.
2.
3.
4.
ESI Corporation (Valid for 3 months from the date of appointment)
Temporary Identity Card

Name
Ins. No Date of
Appointment
Branch Office Dispensary Space for Photograph

Employers
Code No. &
Address

Validity:
X EMP Signature required
Dated: Signature/T.I. of I.P Signature of B.M. with Seal