Form of nomination/modifying nominations for provident/gratuity fund

Part - A: Basic Details

1.

Details of the employee

(i)

Name

(refer note 1)

(ii)

Address

(refer note 2)

(iii)

Permanent Account Number

(iv)

Aadhar

(v)

Gender

(vi)

Date ofBirth

(vii)

Religion

2.

Marital Status

(choose one)

1. Unmarried

2. Married

3. Widow/Widower

3.

Do you have a Family (as per rule 293 and 319)?

1. Yes

2. No

Part - B: Details of the Fund

4.

Type of fund

(choose one)

1. Provident Fund

2. Gratuity

5.

Name of the fund

6.

Account number of the employee

Part - C: Details of nominees

7.

Type of nomination

(choose one)

1. Fresh nomination

2. Modification of existing nomination

8.

Nominee Details

A.

(i)

Name

(refer note 1)

(ii)

Permanent Account Number

(iii)

Aadhar number

(iv)

Address

(refer note 2)

(v)

Age

(vi)

Nominee’s relationship with employee

(vii)

Amount or share of accumulations in the provident fund/ amount or share of gratuity to be paid to each nominee

(viii)

Name of guardian if nominee is a minor

(refer note 1)

(ix)

Permanent Account Number of guardian if nominee is a minor

(x)

Relationship of guardian with employee if nominee is a minor

B.

(Repeat, if required)

Certification by Employee

1. I hereby nominate the person(s) mentioned in (row No. 8) to receive the amount of gratuity* or the amount that may stand to my credit in the provident fund* in the event of my death before that amount becomes payable or, having become payable, has not been paid, and direct that the said amount shall be distributed among the said person(s) in the manner shown under their names.

*2. This nomination is in nature of “Modification of existing Nomination” (refer row No.7), and I hereby cancel the nomination made by me previously as regards the disposal of the amount of gratuity* or the amount that may stand to my credit in the provident fund* in the event of my death.

*3. I do not have a family (refer to row No. 3) and should I acquire a family hereafter, the above nomination (as per row No. 8) should be deemed as cancelled.

Two witnesses to signature. Signature of employee

1. Name:

2. Name:

Date: Place:

Certification by Trustee/Authorized Person

Certified that the above declaration has been signed by before me after, reading the entries* / the entries have been read over to them by me*.

Dated

Signature of the trustee or any person authorized by the trustees in this behalf