Employee No.

1211706
Form-I (Mandatory)
NOMINATION AND DECLARATION FORM
[See Rule 3]

1. Name of person making nominaton (in block leterss CHARITA DANETI

2. Father’s/Husband’s Name

3. Date of Birth 28-Aug-99

4. Sex Female

5. Marital Status Single

6. Address:

Permanent H No.156 ,plot no.22, Radhakrishna Nagar Near Collector bungalow, Srikakulam -532001,
Andhrapradesh

Present H.No.156,plot no.22, Radhakrishna Nagar, Near Collector Bungalow, Srikakulam-532001,

Andhrapradesh

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

Total amount of If the nominee is

share of minor,name,realtonship
accumulatons and address of guardian
Nominee's in credit to be who may receive the
Name of the relatonship with paid to each amount during the minority
nominee/ nominees Address the member Date of Birth nominee of nominee
(1s (2s (3s (4s (5s (6s
Ratna Kumari Plot H No.156 ,plot MOTHER 14- 50.00
Danet no.22, Aug-
Radhakrishna 1974
Nagar Near
Collector bungalow
,Srikakulam-532001 ,
Andhrapradesh .

Srinivasa Rao Plot H No.156 ,plot FATHER 20- 50.00

Danet no.22, Aug-
Radhakrishna 1969
Nagar Near
Collector bungalow
,Srikakulam-532001,
Andhrapradesh.
 < Total % of share should be 100% >

1. Certfied that I have no family and should I acquire a family hereafer, the above nominaton shall be deemed as
cancelled.

2. Certfied 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

Certfied that the above declaraton and nominaton has been signed/thumb impressed before me by
Shri/Smt/Kum____________________________employed in my establishment afer 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 Designaton

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