EMPLOYEE PROVIDENT FUND ORGANISATION

(FORM 2 REVISED)
NOMINATION AND DECLARATION FORM UNDER THE EMPLOYEES PROVIDENT FUNDS AND EMPLOYEES PENSION SCHEMES (PARAGRAPH 33 NAD 61 (I) OF THE EMPLOYEES PROVIDENT FUND SCHEME 1952 AND PARAGRAPH 18 OF THE EMPLOYEES PENSION SCHEME 1995)

1. 2. 3. 5.

Name (In Block Letters) Father's / Husband's Name Date of Birth Address (Temporary)

RAKESH KUMAAR MAHAWAR LAKHPAT RAM MAHAWAR 11.02.1985 Marital Status Married Plot No. 65 , Sunita Colony , Sanganer - Jaipur 302022 - Rajasthan Plot No. 65 , Sunita Colony , Sanganer - Jaipur 302022 - Rajasthan PART - A (EPF)

Account No. 4. Sex

RJ / 15587 / 42 Male

6. Address (Permanent)

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 the Nominee

Address

Nominee's Releationship With The Member 3 Wife

Date of Birth

Total Amount or Share of Accumulations in Provident Funds to be paid to each Nominee 5 Full Amount

1 KESAR DEVI

2 Plot No. 65, Sunita Colony, Sanganer Jaipur

4 13.01.1987

If the Nominee is Minor name & address of the gurdian who may receive the amount during the minority of the nominee 6 ------------------

1. Cetify that I have no family as defined in para (g) of the Employees Provident Fund Scheme 1952 and should I acquire a Family
hereafter the above nomination should be deemed as cancelled.

2. Ceritified that my Father / Mother is / are dependent upon me.

(Signature or Thumb impression of Subscriber) Strike out whichever is not applicable.

PART - B (EPS) Para 18

I hereby furnish below particulars of the members of my family who would be eligible to receive Widow / Child Pension in the event of my Premature Death in Service.

S.No. 1 1 2 3 4 5

Name 2 LAKHPAT RAM MAHAWAR KANTA DEVI KESAR DEVI DURGA KUMAR PAYAL KUMARI

Address of the Family Member 3 Plot No. 65, Sunita Colony, SanganerJaipur Plot No. 65, Sunita Colony, SanganerJaipur Plot No. 65, Sunita Colony, SanganerJaipur Plot No. 65, Sunita Colony, SanganerJaipur Plot No. 65, Sunita Colony, SanganerJaipur

Date of Birth 4 07.05.1958 27.07.1961 13.01.1987 15.08.2003 09.08.2005

Relatonship with Member 5 Father Mother Wife Son Daughter

Certified that I have no family as defined in para 2 (VII) of the Employees's Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish particulars there on in the above form.

RJ / 15587 / 42 Male I hereby nominate the following person for receiving the monthly family Pension (admissible under para 16 (2) (i) & (ii) in the event of my death without leaving any eligible family member for receiving pension. NAME AND ADDRESS OF NOMINEE DATE OF BIRTH RELATIONSHIP WITH MEMBER

D BELOW

inee is Minor dress of the o may receive nt during the the nominee 6

KESAR DEVI Plot No. 65 , Sunita Colony , Sanganer -Jaipur -302022 Rajasthan

13.01.1987

Wife

---------Date 11.05.2010

(Signature or Thumb impression of Subscriber) Strike out whichever is not applicable.

(CERTIFICATE BY THE EMPLOYER)

Certified that the above Declaration & Nomination has been signed/thumb Impressed before me by Mr. / Miss / Mrs. RAKESH KUMAR MAHAWAR 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.

Subscriber)

Date

11.05.2010

(Signature of the Employer or other Authorised Officer of the establishment)

eath in Service.

with Member 5

Date

11.05.2010

Name and Address of the Factory / Establishment (With Rubber Stamp)

ather

Note : To whom can be nominate by subscriber 1.In the case of Male Member his wife, his childrens, his dependent parents, his deceased sons's widow & childrens. 2.In the case of Female Member her husband, her childrens, his dependent parents, her deceased sons's widow & childrens. 3.If subscriber does not have any family, in that case He / She can nominate any person (s) or any institution, whether that relate or not to him / her.and if subscriber acquire a family then the nomination will be deemed as cancelled. In that case subscriber should nominate his / her family members.

other

Wife

Son

ughter

acquire a

i) in the event

MEMBER

riber)

e entries have

stablishment)

ber Stamp)

hat relate or

CHALLAN FORM FOR PAYMENT OF EMPLOYEES'S PROVIDENT / EMPLOYEES'S STATE INSURANCE CONTRIBUTION 1. Name & Address of Factory / Establishment Green Fire Exports
H-1, Special Economic Zone - I, Sitapura Industrial Area - Jaipur 302022 Contact No. : 0141-3278498, 2177148 E-Mail : gfe@dangayachgroup.com ; gfe_emsaru@sify.com EPFO ESIC RJ/15587 1 5 0 0 0 2 0 8 0 3 0 0 0 0 9 0 0 1 EPF EPS 1 M I 2199 7188 2 M II 5 5 EPFO 1 Y 9 9 9 9 0 0 1 Y 2 2 2 ESIC 1 9 4 1 2 2 3 1

2. Establishment Code Number 3. Number of Subscribers / Employees 4. Total Wages 5. Month of Contribution

1 M TOTAL 7488 7188 665

2 M

ESIC 1 Y

1 Y

Employer's Contribution Employees's Contribution Administration Charges Inspection Charges Interest Damages Others / Demand Letter No. & Date Total Mode of Payment

A : EPFO ACCOUNT FUND X XXI XXII 4989 300 6

B : ESIC FUND Account No. 2 3 4 0 9 2 3

6 0

659

9387 Cheque No. Bank Name

659

4989

300

6 Dated D D M

15341 M 1 Y 1 Y

1 Cash

Signature Name, Designation & Seal of Authorised Official * Strike out whichever is not applicable. Contact No. Acknowledgement 27977.00 For Use In Bank Received Rs. (In Figure) Twenty Seven Thousand Nine Hundred Seventy Seven Only Rupees (In Words) Branch Name Cash / Cheque / DD No. dated 1 1 Branch Code No. (Bank) STATE BANK OF INDIA Drawn On Branch Scroll No. Date of Presentation 1 1 Date 1 D D M M Y Date of Realisation 1 1 Date of Credit 1 1
D D M M Y Y

1
Y

Authorised Signature & Seal of Receiving Bank

For office use only :Date Seal / Reg. No. .............................

FORM 13 (REVISED) THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 (Para - 57) [ APPLICATION FOR TRANSFER OF EPF ACCOUNT ]
Note : (I) To be submitted by the member to the present employer for onward transmission to the commissioner EPF by whom the transfer is to be effected. (II) In case the PF transfer is due to from the P.F. Trust of an exempted, the application should be sent direct by the employer to the P.F. Trust of the exempted establishment with a copy to the RPFC Family concerned for detail of the Family Pension Membership. To The Commissioner Employee's Provident Fund Jaipur To M/s
(To be filled in, if note (II) above is applicable)

Sir, I request that my Provident Fund balance along with the Membership Details in Family Pension Fund may please be transferred to my present account under intimation to me. Necessary particulars are furnished below :1. Name of the member (in block letters) 2. Father's / Husband's Name (in case of married woman) 3. Name & Address of the previous employer NITESH BARMAN NIMAI BARMAN GREEN FIRE EXPORTS H-1, SEZ - I, SITAPURA INDUSTRIAL AREA JAIPUR - 302022 RJ / 15587 / 33 REGIONAL PF COMMISSIONER, JAIPUR

4. EPF Account No. with the previous employer 5. By whom the PF Account of the previous establishment is kept 6. FPF Account No. with the previous employer
(if allotted a separate one)

NA

7. Date of leaving service with previous employer 8. Date of Joining the present employer

Date :

Signature / Left Hand impression of the member

* To be filled by the present employer 9. Name & Address of the previous establishment 10. EPF Code & Account No. allotted to the meber 11. FPF Account No. allotted to the member separately, if any 12. By whom the EPF Account of the member in the present establishment is kept Being an un-exempted establishment (a) By Regional Office at

(b) Sub Regional Office at

Being an exempted establishment

(c) By exempted PF, Trust, viz

(d) Private PF, Not covered under the act, viz

13. By whom the FPF Account of the member in the present establishment is kept 14. In whose favour transfer is to be effected, i.e. payee's details

Date :

Signature of Employer / Authorised official with official seal

FOR USE OF P.F. OFFICE ONLY

A sum of ` (Rupees)

is authorised for transfer, vide Annexure, 'K' (Revised) Transfer proceeds to be sent along with Annexure, 'K' (Revised) By D.D. to the Regional PF Commissioner / Office-in-charge of sub Sub Regional Office By D.D. to the PF Trust of the Establishment with License to the details Serial No. 14 above Membership details under Family Pension Fund forwarded to P.F. Regional Office / Sub - Regional Office at

By transfer entries to the Member's Ledger Card bearing number In the present establishment from the Ledger Card bearing number of the previous establishment

Transfer Intimation / Copy of Annexure - K (Revised) to the member placed below

P.I. No.

CLERK

HEAD CLERK

A.A.O

A.O. / A.P.F.C.

Scroll No.

Paid by Cheque No.

dated

Cashier / Clerk

Head Clerk

Assistant P.F. Commissioner

THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 (Paragraph 34) AND THE EMPLOYEES PENSION SCHEME, 1971 (Paragraph 19)

Form - 11 (Revised)

Declaration by a person taking up employment in an establishment in which the Employees Provident Fund & Employees Pension Scheme enforce I NITESH BARMAN
(Name of Employee)

Son / Wife / Daughter of

NIMAI BARMAN

do hereby solemnly declare that : (a) I was employed in M/s and left service on

Green Fire Exports, H-1, SEZ-I, Sitapura - Jaipur 302022

(Name & Address of the immediate previous employer)

prior to that, I was employed in

(Date of Leaving with immediate previous employer)

from
(Name & Address of second immediate previous employer, if any)

to

(Date of Joining & Leaving with second last employer)

(b) I was member of

(Name of PF Trust/Address of PF office of immediate previous employer)

Provident Fund and also / but not of the from and my Account No. (s) was / were

to
(Date of Joining & Leaving with immediate previous employer) (PF Account No. with establishment code of immediate previous employer)

(c) I have / have not withdraw the amount of my Provident / Pension Fund. (d) I have / have not drawn any superannuation benefits in respect of my past service from any employer. (e) I have / have never been a member of any Provident Fund and / or Pension Fund. (f) I am drawing / not drawing Pension under EPS - 95. (g) I am a holder / not holder of Scheme Certificate. (h) Scheme Certificate surrendered / not surrendered.
* Strike out whichever is not applicable.

Date :

Signature or Left Hand Thumb Impression of Employee

(To be filled in by the Employer only when the person employed had noy already been a member of the Employee's Provident Fund) Mr. / Mrs. /Ms.
(Name of Employee)

is appointed as
(Designation)

in M/s
(Name of the present employer)

with effect from

(Date of appointment)

bearing P.F. Account Number

(PF Account No. with establishment code of present employer)

Date :

Signature of Employer or Manager or Authorised Official with official seal