GPF nomination form

                   I  Lalthlamuana, Principal Informatics Officer, Department of ICT, Government of Mizoram hereby nominate the person(s) mentioned below who is/are member(s)/non-member(s) of my family as on 25^th June, 2012 defined in Rule 2 of the General Provident Fund(Central Services) Rules,1960 to receive the amount that may stand to my credit in the Fund as indicated below, in the event of my death before that amount has become payable or having become payable has not been paid.

Sl.No.

Name and full address of the nominee(s)

Relationship with the subscriber

Age of the nominee(Date of birth)

Share payable to each nominee

Contingencies on the happening of whichnomination become invalid

Name, address and relationship of the person(s) if any to whom the right of nominee shall pass in the event of his/her predeceasing the subscriber

If the nominee is not a member of the family as provided in Rule 2, indicate the reason

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2

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Dated this:

day of

at

                                                                                     Signature of the subscriber:

                                                                                            Name in block letters:

                                                                                                                        Designation:   

Two witnesses:

Name:

Name:

Address:

Address:

Signature:

Signature:

Nomination by Shri/Smt/Kumari

Designation:

Date of receipt of nomination:

Signature of Head of Office/Pay & Accounts Officer:

Designation:

Date: