FORM 2 Nomination and Declaration Form for unexempted/exempted establishments Declaration and nomination form under the Employees’ Provident Funds and Employees’ Family Pension Schemes See paragraphs 33 and 61(1) of the Employees’ Provident Funds Scheme, 1952, and paragraph 13 of the Employees’ Family Pension Scheme, 1971. 1. Name (in block letters) : 2. Date of birth : 3. Account No. : PART A (EPF) 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 Employees’ Provident Fund in the event of my death: Name of the nominee/nominees | Address | Nominee’s relationship with the member | Age of nominee(s) | Total amount or share of accumulations in provident fund to be paid to each nominee | If the nominee is a minor name and address of the guardian who may receive the amount during the minority of nominee | (1) | (2) | (3) | (4) | (5) | (6) | | | | | | |
1. Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds 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. Signature/thumb impression of the subscriber Strike out whichever is not applicable. PART B (EPF) I hereby furnish below particulars of the members of my family who would be eligible to receive family pension and life assurance benefits in the event of my premature death in service. Sl. No. | Name and address of the family Member | Age | Relationship with the member | | Name | Address | | | (1) | (2) | (3) | (4) | (5) | 1. | | | | | 2. | | | | | 3. | | | | | 4. | | | | |
Certified that I have no family as defined in para 2(b) of the Employees’ Family Pension Scheme, 1971, and should I acquire a family hereafter, I shall furnish particulars thereon in the above. Date: Signature or thumb impression of the subscriber Strike out whichever is not applicable. CERTIFICATE BY EMPLOYER Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Km.......................................................... employed in my establishment after he/she has read the entries/the entries have been read over to him/her by me and got confirmed by him/her. Signature of the employer or other authorised officer of the establishment. Place : ............................................. Date : .............................................. Designation.................................. Name and address of the factory/establishment or rubber stamp thereof Note: Whom you can nominate (A) Under the Employees’ Provident Funds Scheme: (1) A member of the Employees’ Provident Fund who is married and/or his father/mother is/are dependent upon him can nominate only one or more persons belonging to his family as defined below :— (a) in the case of a male member, his wife, his children, his dependent parents, and his deceased son’s widow and children; (b) in the case of female member, her husband, her children, her dependent parents, her husband’s dependent parents, her deceased son’s widow and children. (2) If the member has got no family, or is a bachelor, nomination may be in favour of any person or persons, whether related to him or not or even to an institution. If the member subsequently acquires a family such nomination shall forthwith become invalid and the member should make a fresh nomination in favour of one or more persons belonging to his family. (B) Under the Family Pension Scheme: (1) On the death of a member of the Family Pension Scheme, his family will be entitled to the benefits under the Family Pension Scheme. The family is defined as under: (i) wife in the case of a male member; (ii) husband in the case of a female member; and (iii) minor sons and unmarried daughters. Explanation: The expressions “sons” and “daughters” shall include children adopted legally before death in service. (2) If the member has got no family, the monthly family pension, on the death of the member, will not be paid. However, life assurance benefit will be paid to the person or persons entitled to receive his provident fund accumulations. | 
