FORM NO.

2 (Revised)
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLSIHMENTS

Declaration and Nomination Form under the employees' Provident Fund and Employees' Pension Scheme
(Paragraph 33 & 61(1) of the employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employee's Pension Scheme, 1995)

1.Name

MR. SABARINATHAN THILLAIAPPAN

2.Father's Name [or

husband's name in
case of married

Thillaiappan

3.Date Of Birth

05/04/1985

4.Sex

Male

5.Marital Status

Married

6.Account No.

KN/52486/539

7.Address
Permanent

18,THANGASAMY TEACHER STREET,, MUHAVOOR, RAJAPALAYAM, TAMILNADU, 626111

Temporary

29, 1st cross, Mega City layout,(BEML layout,), Maragondanahalli Main Road,, Near Mother Terasa
School,K.R Puram Post., Bengaluru, KARNATAKA, 560016
PART - A (EPF)

I
hereby
nominate
the
person(s)/cancel
the
nomination
made
by
me
previously
receive the amount standing to my credit in the Employee's Provident Fund, in the event of my death.

Name of the
nominee/nominees

Address

Nominee's
relationship
with the
member

and

Date of
Birth

nominate

the

person(s)

Total amount
or Share of
accumulation
s in
Provident
Fund to be

mentioned

below

to

If the nominee is a
minor, name &
relationship & address
of the guardian who
may receive the
amount during the

(In %)

1
*Certified that I have no family as defined in para 2(g)
family
hereafter the above nomination should be deemed as cancelled.

4
of

the

Employees'

5
Provident

Fund

6
Scheme,

1952

and

should

acquire

*Certified that my father/mother is/are dependent upon me.

Form 2 Report

( Sabarinathan Thillaiappan )
Signature or thumb impression of the Subscriber

Page 1 of 2

Emp Code

708941

RPFC Bangalore

Initials & Round Stamp

(2)
PART - B(EPS)
(Para 18)
I hereby furnish
event of my death.

below

particulars

Sr.
No.

Name and address of the

family member

of

the

members

of

my

family

who

would

be

eligible

Address

to

receive

widow/children

Date of
Birth

in

the

Relationship with
the member

Pension

_________

* Certified that I have no family, as defined in para

family hereafter I shall furnish particulars thereon in the above form.

2(vii)

of

the

Employees

I hereby nominate the following person for receiving the monthly widow pension
the event of my death without leaving any eligible family member for receiving pension.
Name & address of the
nominee

Date :

02/09/2015

Place :

Bangalore

Pension

(admissible

Scheme.

under

1995

and

16

2(a)

para

Date of Birth

should

&

acquire

ii

in

Relationship with the

member

( Sabarinathan Thillaiappan )
Signature or thumb impression of the Subscriber
CERTIFICATE BY EMPLOYER

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

MR. SABARINATHAN THILLAIAPPAN

employed
in
my
confirmed by him/her

establishment

after

he/she

has

read

the

entires/entires

For

Place :

have

been

read

over

to

him/her

by

me

and

ALLSCRIPTS (INDIA) PRIVATE LIMITED

Date :
Name and address of the Factory/Establishment
ALLSCRIPTS (INDIA) PRIVATE LIMITED
Maruthi Infotech Center, 4th Floor, Intermediate Ring Road,
PIN

560071

Additional information to be certified by employer

MR. SABARINATHAN THILLAIAPPAN

Name

Date of membership

EPF Scheme 1952

14/04/2014

[]

A/c No.
EPF Scheme, 1971

[]

For

Date :

02/09/2015

Place :

Bangalore

Page 2 of 2

Emp Code

708941

KN/52486/539
Pension Scheme, 1995

[]

ALLSCRIPTS (INDIA) PRIVATE LIMITED

RPFC Bangalore

Initials & Round Stamp

got