Applicant Id : 579340

FORM-2(REVISED)
Pension Number : MH/BAN/48475/

These details are picked from

Declaration and Nomination Form under the Employees Provident Fund and Employees Pension Scheme (Rule 25Application
of the Tata Consultancy
Link Services Employees Provident
NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Fund Rules & Paragraph 18 of the Employees Pension Scheme, 1995)

1.

Name in CAPITALS :

Khanolkar, Mr. Santosh Gopal

2.

Father's/Husband's Name :

Mr. Gopal Mukund Khanolkar

3.

Date Of Birth:

09/04/1973

4.

Male/Female :

Male

5.

Marital Status :

Married

6.

PF Account Number :

MH/BAN/48475/........................

7.

Address : Permanent :

B/10, THE DADAR CHSL, SHARADASHRAM, , BHAVANI SHANKAR ROAD,

If you
have transferred
DADAR (WEST), MUMBAI,
Maharashtra,
India - 400028

Date of joining EPF Scheme,1952:

the PF from your

earlier Company to TCS then the date of
B/10, THE DADAR CHSL, SHARADASHRAM, , BHAVANI SHANKAR ROAD,
joining
EPF and
should be the date of
DADAR (WEST), MUMBAI,
Maharashtra,
IndiaEPS
- 400028
previous Company, otherwise the date of
08/06/1998
joining TCS will DOJ EPF and EPS

Date of joining E.P.Scheme,1995:

08/06/1998

Temporary :

8(a.)
(b.)

PART - A ( EPF )
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.

Nominee details entered in GRS>Nomination Form link in Part A of

Provident
Nomination
areof the Nominees
Address
NameFund
of Nominee
/
Nominees
displayed here.

Whom to nominate: Please refer definition of family Part A on Page 3

Nominee's relationship
with the member

Date of Birth

Total Amount of share of

accumulations in
Provident Fund to be
paid to each nominee

If the Nominee is minor,

name, relationship and
address of the guardian who
may receive the amount
during the minority of
nominee

Ms. Neha Santosh

Khanolkar

B-10, The Dadar CHSL,

Sharadashram, Bhavani
Shankar Road, Opp.
Sharadashram school,

Spouse

10/09/1977

100

NA

Mumbai, Mumbai City,

Maharashtra, India 400028

1. Certified that I have no family as defined in Para 2(g) of the Employees Provident Fund Scheme, 1952 and should I acquire a family hereafter the above nomination
should be deemed as cancelled.
2. Certified that my father/ mother is / are dependent upon me.

Which is relevant, you can

refer page 3 for the same

Sign here on the printout

Signature of the Member/Subscriber

Whom to nominate: Please refer

definition of family Part B on Page 3
PART - B ( EPS )
(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children Pension in the event of my death.
Serial No.

Name of the Family Member

Address of the Family

Member

Date of Birth

Relationship with the

Member

MS. Neha Santosh Khanolkar

B-10, The Dadar CHSL,,

10/09/1977

Spouse

Sharadashram, Bhavani
Shankar Road, Opp.
Sharadashram school,

Nominee details entered in GRS -> Nomination

Mumbai, Mumbai City,
Maharashtra, India - 400028
Forms link in Part B of Provident Fund
Nomination
are displayed here if your status is
Certified that I have no family, as defined in Para 2 (vii) of Employees Pension Scheme , 1995 and should I acquire a family hereafter I shall furnish particulars thereon in
Married
the above form..
Details of other Nominees
I hereby nominate the following person for receiving the monthly widow pension (admissible under Para 16 (2)(a)(i) and (ii) of the Employees
Pension
Scheme, 1995
in the
entered
is displayed
here
event of my death without leaving any eligible family member for receiving pension.
Name and Address of the Nominee

Date of Birth

Relationship with the Member

MR. Gopal Mukund Khanolkar

B-10, The Dadar CHSL, Sharadashram, Bhavani

17/04/1944

Father

Shankar Road, Opp. Sharadashram school, Mumbai,

Mumbai City, Maharashtra, India - 400028

Date:

Enter the date when you

sign the Form.

Sign here on the printout

Enter the date, when you

sign the Form.

Signature of the Member/Subscriber

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed before me by Shri/ Smt./Kumari ..............................................(Employee Number:........................)
employed in my establishment after he/she has read the entries have been read over to him/her by me and got confirmed by him/her.

Date:

Do not
sign here
Signature of the Employer or
Other Authorized Officer of the Establishment

Guidelines: WHOM YOU CAN NOMINATE

(A) PROVIDENT FUND: UNDER THE EMPLOYEES' PROVIDENT FUND SCHEME: PART A
A member of Employees' Provident Fund who is married and / or his father/
mother is/are dependent upon him can nominate only one or more persons
belonging to his family only as defined below:
In the case of a male member, his wife, his children, his dependent parents and his deceased son's widow and
children;
In the case of a female member, her husband, her children, her dependent parents, her husband's dependent
parents, her deceased son's widow and children.if the member has got no family, or is a bachelor nomination may
be in favour of any person or persons, whether related to him or not or even to an institution.
If the member subsequently acquires a family, such nomination shall forthwith become invalid and the member should
make a fresh nomination in favour of one or more persons belonging to his family.

(B) PENSION: UNDER THE FAMILY PENSION SCHEME: PART B

On the death of a member of the Family Pension Scheme, his family will be entitled to the benefits under the Family
Pension Scheme. The family is defined as under:wife in the case of a male
member; husband in the case
of a female member; and
minor sons and unmarried
daughters.
Explanation: The expression "sons" and ""daughters" shall include children
adopted legally before death in service. if the member has got no family, the
monthly family pension, on the death of the member, will not be paid. However,
Life Assurance Benefit will be paid to the person or persons entitled to receive his provident fund accumulations.