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    {
      "id": "019ab183-3e00-7dc7-9b7b-0f981d40f9ca",
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      "result": "FORM 2 (Revised)

NOMINATION AND DECLARATION FORM  
(For Unexempted / Exempted Establishments)  
Declaration and Nomination Form under the Employees Provident Funds & Employees’ Pension Scheme  
(Paragraph 33 and 61(1) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18  
of the Employees’ Pension Scheme, 1995)

1. Name: Employee  
   (in block letters)  
2. Father’s / husband’s Name: Whatever applicable  
3. Date of Birth: employee’s DOB  
4. Sex: Male / Female  
5. Marital Status: Single / Married  
6. Account No.: — (Blank)  
7. Address:  
   Permanent: to be mentioned  
   Temporary: to be mentioned  

PART A (EPF)  
I hereby nominate the person(s) / cancel the nomination made by me previously and nominate the person(s), mentioned below receive the amount standing to my credit in the Employees’ Provident Fund, in the event of my Death:

<table>
  <tr>
    <th>Name of the nominee/ nominee’s</th>
    <th>Address</th>
    <th>Nominee’s relationship with the member</th>
    <th>Date of Birth (must)</th>
    <th>Total amount of share of accumulations in Provident Fund to be paid to each nominee</th>
    <th>If the nominee is a minor, name & relationship & address of the guardian who may receive the amount during the minority of nominee</th>
  </tr>
  <tr>
    <td>Nominee #1</td>
    <td>Nominee’s address</td>
    <td>Father / Mother</td>
    <td>Nominee DOB</td>
    <td>100%</td>
    <td>2</td>
  </tr>
  <tr>
    <td>Nominee #2 (if any)</td>
    <td></td>
    <td>— same</td>
    <td>same</td>
    <td></td>
    <td>Sum should be 100% only</td>
  </tr>
  <tr>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
  </tr>
  <tr>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
  </tr>
  <tr>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
    <td></td>
  </tr>
</table>

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.

* Strike out whichever is not applicable

Signature or thumb impression of the Subscriber  
Signature"
    }
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