Employees Provident Fund Scheme

Form 2(revised)
Paragraphs 33 & 61(1) of the Employees Provident Funds Scheme, 1952 and
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
and Employees’ Family Pension Schemes
1. Name
(in block letters)
2 Father’s / Husband’s Name
3 Date of Birth
4 Sex
5 Marital Status
6 Account No.
7 Address
Permanent
Temporary
8 (A) Date of Joining of EPF Scheme, 1952
(B) Date of Joining of EPF Scheme, 1971
(C) Date of Joining of EPF Scheme, 1995

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 Address Nominee’s Age of Total amount If the
nominee/nomi relationship Nominee(s) or share of Nominee is a
nees with the accumulation minor, name
member s in Provident & relationship
Fund to be & address of
paid to each the guardian
nominee 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 dependant upon me.

Signature or thumb impression

of the subscriber
*Strike out whichever is not applicable

Part B (EPS)
(Part 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.
Sl. No. Name & 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 (vii) of the Employees’ Pension Scheme,
1971 and should acquire a family hereafter I shall furnish particulars thereon in the above form.

Dated Signature of 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 Designation
Date Name & Address of the Factory /
Establishment or rubber stamp thereof.

Note - Who you can nominate

(A) UNDER THE EMPLOYEES’ PROVIDENT FUND 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 this 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 a 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.