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Statutory Documents - CBRE
Statutory Documents - CBRE
To be filled in by the employee after reading instructions mentioned on next page. Two Postcard Size photographs
are to be attached with this form. This form is free of cost.
(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 (with City, State & Pin Code)
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.
Insurance Number
Branch Office Space for Photograph
Dispensary
Employer Code & Address CBRE South Asia Pvt. Ltd. 19th Floor, DLF Square, M Block,
Jacaranda Marg, DLF City, Phase – 2, Gurgaon 122002
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2. “Family” means all or any of the following relatives of an Insured Person namely:-
(i) spouse (ii) a minor legitimate or adopted child dependent upon the I.P;(iii) a child who is wholly dependent on the earnings of the I.P.
and who is (a)receiving education, till he or she attains the age of21 years (b)an un married daughter; (iv) a child who is infirm by reason of any
physical or mental abnormity or injury and is wholly dependent on the earnings of the I.P. so long as the infirmity continues; (v) dependent
parents (Please see Section 2 clause 11 of the ESI Act 1948 for details).
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FORM 2 (Revised)
Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme
Paragraphs 33 & 61 (1) of the Employees Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension scheme,
1995)
Aadhar Number
Father’s/Husband’s Name
Date of Birth
Gender
Marital Status
Account Number
Permanent Address
Temporary Address
Date of Joining
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 Address Nominee DOB Total amount If Nominee is a minor, name and
Nominee/Nominees Relation of share of relationship & address of the
with accumulations guardian who may receive the
member in Provident amount during the minority of the
Fund to be nominee
paid to each
nominee
1 2 3 4 5 6
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
*Strike out whichever is not applicable. Signature/Thumb Impression of the (Employee) Member/Subscriber
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1 2 3 4 5
1
2
3
4
5
6
** Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a family hereinafter
I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2(a)(i) and (ii) in the event
of my death without leaving any eligible family member for receiving Pension
1 2 3
CERTIFICATE 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
entries/entries have been read over to him/her by me and got confirmed by him/her.
Designation
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Para 33: - Declaration by persons already employed at the time of institution of the fund
Every person who is required or entitled to become a member of the Fund shall be asked forthwith by his employer
to furnish and shall, on such demand, furnish to him, for communication to the Commissioner, particulars
concerning himself and his nominee required for the declaration form in Form 2. Such employer shall enter the
particulars in the declaration form and obtain the signature or thumb impression of the person concerned
Para 61 - Nomination
1. Each member shall make in his declaration in Form 2, a nomination conferring the right to receive the amount
that may stand to his credit in the Fund in the event of his death before the amount standing to his credit has
become payable, or where the amount has become payable before payment has been made.
2. A member may in this nomination distribute the amount that may stand to his credit in the Fund amongst his
nominees at his own discretion.
3. If a member has a family at the time of making a nomination, the nomination shall be in favour of one or more
persons belonging to his family. Any nomination made by such member in favour of a person not belonging to
his family shall be invalid. Provided that a fresh nomination shall be made by the member on his marriage and
any nomination made before such marriage shall be deemed to be invalid.
4. If at the time of making a nomination the member has no family, the nomination may be in favour of any person
or persons but if the member subsequently acquires a family, such nomination shall forthwith be deemed to be
invalid and the member shall make a fresh nomination in favour of one or more persons belonging to his family.
4A. Where the nomination is wholly or partly in favour of a minor, the member may, for the purposes of this
scheme appoint a major person of his family, as defined in clause (g) of paragraph 2, to be the guardian of the
minor nominee in the event of the member predeceasing the nominee and the guardian so appointed. Provided
that where there is no major person in the family, the member may, at his discretion, appoint any other
person to be a guardian of the minor nominee.
5. A nomination made under sub-paragraph (1) may at any time be modified by a member after giving a written
notice of his intention of doing so in form 2. If the nominee predeceases the member, the interest of the
nominee shall revert to the member who may make a fresh nomination in respect of such interest.
6. A nomination or its modification shall take effect to the extent that it is valid on the date on which it is received
by the commissioner.
i. In the case of a male member, his wife, his children, whether married or unmarried, his dependent
parents and his deceased son’s widow and children.
Provided that if a member proves that his wife has ceased, under the personal law governing him or the
customary law of the community to which the spouses belong, to be entitled to maintenance she shall no longer
be deemed to be a part of the member’s family for the purpose of this scheme, unless the member subsequently
intimates by express notice in writing to the commissioner that she shall continue to be so regarded; and
ii. In the case of a female member, her husband, her children, whether married or unmarried, her
dependent parents, her husband’s, dependent parents, her deceased sons widow and children;
Provided that if a member by notice in writing to the commissioner expresses her desire to exclude her husband
from the family, the husband and his dependent parents shall no longer be deemed to be a part of the member’s
family for the purpose of this scheme, unless the member subsequently cancels in writing any such notice.
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Explanation: - In either of the above two cases, if the child of a member [or as the case may be, the child of a
deceased son of the member] has been adopted by another person and if, under the personal law of the adopter,
adoption is legally recognized, such a child shall be considered as excluded from the family of the member.
Para 18: Particulars to be supplied by the Employees already employed at the time of commencement of the
Employees’ Pension Scheme.
Every person who is entitled to become a member of the Employees’ Pension Fund shall be asked forthwith by his
employer to furnish and that person shall, on such demand, furnish to him for communication to the Commissioner
particulars concerning himself and his family in the form prescribed by the Central Provident Fund Commissioner.
Explanation – The expression “Sons” and “daughters” shall include children (Legally adopted by the
member)
Note: Members can nominate a person to receive benefits under the Employees’ Pension Scheme 1995 where a
member is unmarried or does not have any family. Such nominee shall be paid pension equal to widow pension in
case of death of member.
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Form No. 11
(to be retained by the employer for future reference)
(Declaration by the person taking up employment in any establishment on which EPF Scheme, 1952 and / or EPS 1995 is applicable)
1 Name of Member Rohit Patnala
2 Father’s Name (✔) Spouse’s Name ( )
(Please Tick whichever is applicable) P. Uma Shankar
Undertaking
1. Certified that the particulars are true to the best of my knowledge
2. I authorize EPFO to use my Aadhar for verification/authentication/eKYC 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 PF account (The
transfer would be possible only if the identified KYC detail approved by previous employer has been verified by the present employer
using his Digital Signature Certificate)
4. In case of changes in above details, the same will be intimated to the employer at earliest.
The member Mr./Ms./Mrs. __________________________ has joined on ___________________ and has been allotted PF number __________
_________________________
In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
(Post Allotment of UAN) The UAN allotted for the member is __________________________________________________________________
Please tick 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
In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995
The above PF Account Number /UAN of the member as mentioned in (A) above has been tagged with his/her UAN/Previous Member ID as
declared by the member. Please Tick appropriate option:
( ) The KYC details of the above member in the UAN database have been approved with Digital Signature Certificate and
transfer request has been generated on portal
( ) As the DSC of the establishment are not registered with EPFO, the member has been informed to file physical claim
(Form 13) for transfer of funds from his previous establishment.
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CBRE South Asia Pvt. Ltd. 19th Floor, DLF Square, M Block, Jacaranda Marg, DLF City Phase – 2, Gurgaon – 122002
1. Rohit Patnala
I, (Name of the Employee) _______________________________________________ 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 a/are 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.
4. I hereby declare that
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)
3.
Statement
Name of employee in full. : Rohit Patnala
____________________
Gender : ____________________
Male
Religion : Hindu
____________________
Whether unmarried/married/widow/widower : ____________________
Unmarried
Department/Branch/Section where employed. : ____________________
Post held with Ticket or Serial No., if any : ____________________
Date of appointment. : ____________________
E-1301, Vajra’s
Permanent address. : ____________________
Jasmine County
Village- Financial District
Thana - Gachibowli Sub-division Nanakramguda Post Office - Gachibowli District RR
State Telangana
Place - Hyderabad
Date 09/07/2021 Signature/Thumb impression of the employee
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Declaration by witnesses
1. P. Uma Shankar 1.
2. P. Padma Latha 2.
Place Hyderabad
Date 09/07/2021
Certified that the particulars of the above nomination have been verified and recorded in this establishment
Designation
Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer
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