Employee Code 56454 New Form No.

- 11 - Declaration Form
Present Company's Name Noida - Kronos Solutions India Private Limited (To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Funds Scheme, 1952 ( Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme 1952 and/or EPS 1995 is applicable)
1 Name of the member Sabhyasachi Sural
2 Father's Name ✔ Spouse's Name
Partha Sarthi Sural
(Please tick whichever is applicable)

3 Date of Birth (DD/MM/YYYY) 04/05/1992

4 Gender : (Male/Female/Transgender) Male
5 Marital Status (Married/Unmarried/Widow/Widower/Divorcee) Married
6 (a) Email ID: [email protected]
(b) Mobile No.: 8800759640
7 Whether earlier a member of Employees' Provident Funds Scheme 1952 (Yes/No) Yes

8 Whether earlier a member of Employees' Pension Scheme, 1995 (Yes/No) Yes

Previous employment details: [if Yes to 7 AND/OR 8 above]
a) Universal Account Number: 101154944649
9 b) Previous PF Account Number: DLCPM15597860000040453
c) Date of exit from previous employment (DD/MM/YYYY) 23/06/2025
d) Scheme Certificate No. (if issued)
e) Pension Payment Order (PPO) No. (if issued)
a) International Worker (Yes/No.) ( i.e. Whether having other than Indian Passport) No
10 b) If yes, state country of origin (India/Name of other country)
c) Passport No.
d) Validity of Passport [(DD/MM/YYYY) to (DD/MM/YYYY) to
KYC Details: (attach self attested copies of following KYCs)
a) Bank Account No. & IFS Code 071901515451 & ICIC0000719
11 b) Aadhaar Number 730881701779
c) Permanent Account Number (PAN), if available DDRPS8940E

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhaar for verification/authentication/eKYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present P.F. Account.
(The transfer would be possible only if the identified KYC detail approved by previous employer has been verified by present employer using his Digital Signature Certificate)
4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date: 30/06/2025
Place: Noida Signature of Member
DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs. has joined on and has been allotted PF Number

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
* (Post allotment of UAN) The UAN allotted for the member is
* Please Tick the Appropriate option:
The KYC details of the above member in the UAN database
() Have not been uploaded.
() Have been uploaded but not approved
() Have been uploaded and approved with DSC
C. In case the person was earlier a member of EPF Scheme 1952 and EPS, 1995:
* The above PF Account number/UAN of the member as mentioned in (A) above has been tagged with his/her UAN/Previous member ID as declared by member.
* Please Tick the Appropriate Option
() The KYC details of the above member in the UAN database have been approved with Digital Signature Certificate and transfer request has been generated on portal.
() As the DSC of establishment are not registered with EPFO, the member has been informed to file physical claim (Form 13) for transfer of funds from his previous establishment.

Date: Signature of Employer with Seal of Establishment

 Print Form
FORM 2 (Revised)
Employee Code 56454
(For Unexempted / Exempted Establishment)

NOMINATION AND DECLARATION FORM

(Declaration and Nomination Form under the Employees' Provident Funds and Employees' Pension Scheme)
(Paragraphs 33 & 61 (1) of the Employees' Provident Funds Scheme, 1952 and paragraph 18 of the Employees' Pension Scheme, 1995)

1 Name (in Block Letters) : SABHYASACHI SURAL

2 Father's/Husband's Name : Partha Sarthi Sural

3 Date of birth : 04/05/1992

4 Sex : Male
5 Marital Status : Married

6 Account No. (PF/EPS Number) :

7 Address (Residential) Permanent : D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024

Temporary :

8 Date of Joining - EPF/EPS : 30/06/2025

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:
Name and Address of the nominee/ nominees Nominee's Date of Birth Total amount or If the nominee is a minor,
relationship share of name and relationship and
with the accumulations in address of the guardian who
member Provident Fund to may receive the amount
be paid to each during the minority of
nominee (%) nominee

(1) (2) (3) (4) (5)

Suchitra Sural 33%
D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Mother 09/08/1961
Partha Sarthi Sural 33%
D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Father 05/06/1960
Jayanti Sarkar 34%
D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Wife 28/04/1999

100 %
1 * Certified that I have no family as defined in para 2(g) of the Employees' Provident Funds 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.
3. * Strike out whichever is not applicable.

_________________________________________
Signature or thumb impression of the subscriber
Note: - A Fresh nomination shall be made by the member on his marriage and any nomination made before such marriage shall be deemed to be
invalid

# If Married -> Spouse, Children (married or unmarried), his/her dependent parents, deceased son's widow and children.
If unmarried then Parents, Brother, Sister or any other person(s).
Name of Present Company
 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.

Sl. No. Name and address of the family members Date of Birth Relationship with
the member

(1) (2) (3) (4)

Jayanti Sarkar 28/04/1999

1
D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Wife
2

** 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 the above form.

I hereby nominate the following persons for receiving the monthly widow pension (admissible under para 16 2(a) (i) and (ii) of Employees' Pension Scheme,
1995 in the 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

(1) (2) (3)

Suchitra Sural 09/08/1961

D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Mother
Partha Sarthi Sural 05/06/1960
D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Father

Date 30/06/2025
.............................................................................
Signature or thumb impression of the subscriber
**Strike out whichever is not applicable.

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

Place : ................................................................................................
Signature of the Employer or other authorised
Dated the : officer of the establishment
Designation..........................................................
Name and address of the Factory/Establishment
or rubber stamp thereof
$ - Applicable if Married -> To Spouse and Children (include children adopted legally before death in service.

$$ - Applicable to both Married and unmarried - (1) Married ----- To any person(s) other than spouse and children.
(2) Unmarried ----- To Parents, Brother, Sister or any other person(s).
 Payment of Gratuity (Central) Rules
FORM 'F'
See sub-rule (1) of Rule 6

Nomination

To,
(Give here name or description of the establishment with full address)
Noida - Kronos Solutions India Pvt. Ltd. - Address: Okaya Towers, Tower 4, Block B, B 5, Sector 62, Noida, Uttar Pradesh 201301.

I, Shri/Shrimati/Kumari
Sabhyasachi Sural
(Name in full here)
whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to
receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death
before that amount has become payable, or having become payable has not been paid and direct that the
said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the meaning of clause
(h) of Section 2 of the Payment of Gratuity Act, 1972.
3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the said Act.

4 (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.
5. I have excluded my husband from my family by a notice dated the to
the controlling authority in terms of the proviso to clause (h) of Section 2 of the said Act.
6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Name in full with full Relationship with Age of Proportion by which

address of nominee(s) the employee nominee the gratuity will be
shared

(1) (2) (3) (4)

1. Partha Sarthi Sural,D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Father 66 33

2. Suchitra Sural,D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Mother 63 33
3. Jayanti Sarkar,D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024 Wife 26 34
So
on.
 Statement
1. Name of employee in full Sabhyasachi Sural

Male
2. Sex
3. Religion Hindu

4. Whether unmarried/married/widow/widower Married

5. Department/Branch/Section where employed

6. Post held with Ticket No. or Serial No., if any
7. Date of appointment
8. Permanent address: D 37,Amar Colony,Lajpat Nagar-4, New Delhi-110024
Village Thana Sub-division
Post Office District State

Place: Noida
Signature/Thumb-impression of the
Employee
Date: 30/06/2025

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses. Signature of Witnesses.
1. 1.

2. 2.

Place:
Date:

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.
Employer's Reference No., if any Signature of the employer/Officer authorised
Designation

Date: Name and address of the establishment or

rubber stamp thereof.
 Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified by the employer.

Date:
30/06/2025 Signature of the Employee

Note.—Strike out the words/paragraphs not applicable.