This document contains a nomination and declaration form for an employee's provident fund and pension scheme. It includes fields for the employee's personal details and nomination of beneficiaries. In Part A, the employee nominates his wife, Saranya, to receive 100% of his accumulated provident fund in the event of his death. In Part B, he provides details of his family member, listing only his wife Saranya, to receive widow pension if he were to die without other eligible family. The employee signs the form, confirming the details and nominations, and the employer also signs to certify the employee signed or thumb printed the form in their presence.

1. (For Unexempted/ exempted Establishments)
(Paragraph 33 and 61(1) of the Employees ' Provident Fund Scheme, 1952 &
Paragraph 18of the Employees 'Pension Scheme 1995 )
Declaration and Nomination Form under the Employees' Provident Funds & Employess' Pension Scheme
1. Name 2. Father's / Husband Name
3. Date Of Birth 4. Sex
5. Marital Status 6. Account No.
7. E Mail Address 8. Phone No.
9. Address
Permanent
Temporary
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) , mention
below receive the amount standing to my credit in the Employee' Provident Fund , in the event of my Death
PART A (EPF)
Name of the
nominee/nominee's
Address Nominee's
relationship with
the member
Date Of
Birth
Total Amount or
Share of
accumulation in
Provident Fund
to be paid to
each nominee
If the nominee is minor
,name & relationship &
address of the guardian
who may receive the
amount during the
NOMINATION AND DECLARATION FORM
NO.389, 2ND FLOOR,,VIJMAPUR, KUVEMPU NAGAR,,BANGALORE,,KARNATAKA,560017
NO.389, 2ND FLOOR,,VIJMAPUR, KUVEMPU NAGAR,,BANGALORE,,KARNATAKA,560017
PY/KRP/0052857/000/0000063
FORM 2 (Revised)
DEEPAK B
31-Mar-1984
MARRIED
BALASUBRAMANIAN A
MALE
9886295459dbalasubramanian@sprinklr.com
,,,,,
NO.389, 2ND
FLOOR,,VIJMAPUR,
KUVEMPU
NAGAR,,BANGALORE,,KARN
ATAKA,560017
19-May-1988 100SARANYA P WIFE
*Cettified that i have no family as defined in para2 (g) of the Employees' Provident Fund Scheme,1952 and
should I acquire a familly hereafter the above nomination should be deemed as cancelled.
*strike out whichever is not applicable Signature or thumb impression of the Subscriber
* Certified that my father / mother is / are dependent upon me.

2. PART B (EPS)(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible receive
widow/children pension in the event of my death
Sl.
No
1.
Name and Address of the family member Date Of Birth
4
Relationship with
member
5
Address
3
Name
2
NO.389, 2ND
FLOOR,,BANGALORE,,KARNATAKA,560
1 SARANYA P 19-May-1988 WIFE
I hereby nominate the following person for receving the monthly widow pension (admissible under para 16 2(a)(i)(ii) in the
event of my death wihout leaving any eligible family member for receiving pension
**Certified that I have no family as defined in para 2 (vii)of the Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in above form.
Relationship with the memberDate Of BirthName and Address of Nominee
Name and address of the Factory/
Establishment or rubber stamp thereof
Designation
Signature of the employer or the other
authorized Officers of the establishment
Place :
Date :
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.
CERTIFICATE BY EMPLOYER
Signature or thumb impression of the Subscriber*strike out whichever is not applicable
Date :