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FORM 2 (Revised)
(For Unexempted /Exempted EstabIi!3hments)

(Declaration and Nomination Form under the Employees' Provident Funds and Employees’ Pension Scheme)
(Paragraphs 33 8 61 (1) of the Employees’ Provident Funda Scheme, 1952 and paragraph :1B of the Employees’ Pension Scheme, 1995)

Name (in Block Letters) :

First Name Middle Name Last Name

Father's/Husband’s Name :
First Name Middle Name Last Name

Date of birth :

Sex :

Marital Status Single Married Divorced Widowed

Account No.
(PF/EPS Number)

Address (Residential) Permanent

Temporary

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 and Address of the nominee/ nominees Nominee’s relationship Date of Birth Total amount If the nominee is a minor, name and
with the member or share of relationship and address of the
accumulations in guardian who may receive the amount
Provident Fund to during the minority of nominee
be paid to each
nominee (%)
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.
3. * Strike out whichever is not applicable.
Signature or thumb impression of the subscriber

Note: - 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
# If Married —> Spouse, Children (married or unmarried), his/her dependent parents, deceased son's widow and children. If unmarried then Parents,
Brother, Sister or any other person(s).

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.
SI.No. Name and address of the family members Date of Birth Relationship with the member
(1) (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.
I hereby nominate the following persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii) of Employees’ Pension
Scheme, 1995 in the event of my death without leaving any eligible family member for receiving Pension. $$

Name and Address of the Nominee Date of Birth Relationship with the member
(1) (2) (3)

**Strike out whichever is not applicable. Signature or thumb impression of the subscriber

Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kumari 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.

Place:

Designation..............................................
Signature of the Employer or other authoFiSed Name and address of the Factory/Establishment
Officer of the establishment or rubber stamp thereof
Employee Code: New Form No.-11-Declaration Form
(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 employ mentioning establish mention which EPF Scheme, 1952 and/or EPS, 1995 is applicable)

1 Name of the member

2 Father's Name £ Spouse's Name £

(Please tick whichever is a applicable)

3 Date of Birth:(DD/MM/YYYY)

4 Gender:(Male/Female/Transgender)

5 Marital Status:(Married/Unmarried/Widow/
Widower/Divorcee)

6 (a) Emai lID:

(b) Mobile No.:

7 Whether earlier a member of Employees' Provident Fund

Scheme, 1952 Yes /No

8 Whether earlier a member of Employees' Pension

Scheme, 1995 Yes/No

9 Previous employment details: [If yes to 7 AND/OR 8 above]

(a) Universal Account Number:

(b) Previous PF Account Number:

(c) Date of exit from previous employment: (DD/MM/YYYY)

(d) Scheme Certificate No. (if issued)

(e) Pension Payment Order (PPO) No. (if issued)

10 (a) International Worker: Yes /No

(b) If yes, state country of origin (India/Name of other country)

(c) Passport No.

(d) Validity of Passport [(DD/MM/YYYY) to (DD/MM/YYYY)]

11 KYC Details: (attach self attested copies of following KYCs)

a) Bank Account No. & IFS Code

b) AADHAR Number

c) Permanent Account Number (PAN), if available

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/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. A ccount.
(The transfer would be possible only if the identified KYC detail approved by previous employer has been verified by present employer
Using his Digital Signature Certificate)
4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date:
Place: Signature of Member
 DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs.……………………………………………….…………has joined on…........................ and has been allotted PF

Number……………………………….

B. 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 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

C. 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 member.

* Please Tick the 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 establishment are not registered with EPFO, the member has been in formed to file physical claim (Form-13)

For transfer of funds from his pervious establishment.

Date: Signature of Employer with Seal of Establishment