FIRST SCHEDULE

See Rules 8 (3)

FORM OF NOMINATION

Account No...................................................... I ….......................................................................................................... hereby nominate the person(s)

mentioned below who is/are member(s)/non-member(s) of the family as defined in the rule 2 of the General Provident Fund (West Bengal Services)
Rules to receive the amount that may stand to my credit in the fund as indicated by below, in the event of my death before that amount has become
payable or having become payable has not been paid.

Name and full Relationship with the Age of the nominee(s) Share payable to each Contingencies on the Names, address & If the nominee is not
address subscriber nominee happening of which relationship of the a member of the
of the nominee(s) the person family as
nomination will if any, to whom the provided in Rule 2
become right indicated the reasons
invalid. of nominee shall pass
in
the event of his/her
predecessing the
subscriber
1 2 3 4 5 6 7

Dated this................................day of............. ….....................19 at..............................................

Two witness to signature Signature

Name and address,
Signature of the subscriber,

1. ….................................................................................................................. Name in Block letters.................................................................................................................

2. ….................................................................................................................. Designation.................................................................................................................................