FORM II
[See sub-rule (4) of rule 3]
Fresh nomination

To
(Give here name and address of employer together with name and full address of the mine).
I…………… (name in full here) whose particulars are given in the statement below have acquired a family within the meaning of Cl. (d) of rule 2 of the Payment of Undisbursed Wages (Mines) Rules, 1989, with effect from……(date here) in the manner indicated below and therefore nominate afresh the person mentioned below to receive all amounts payable to me as wages if such amounts could not or cannot be paid on account of my death before the payment or on account of my whereabouts not being known.
2. 1 hereby certify that the person nominated by me is a member of my family within the meaning of Cl. (d) of rule 2 of the said rules.
3.         (a) My father/mother/parents is/are not dependent upon me.
(b) My husband's father/mother/parents is/are not dependent on my husband.

Nominee
Name and address of the nominee	Nominee’s relationship with the employed person	Age of nominee
1	2	3

Manner of acquiring a “family”
(Here give details as to how a family was acquired, whether by marriage or parents being re -dependent or through other process like adoption)
Statement
1. Name of the employed person in full.
2. Sex
3. Religion
4. Whether unmarried/married widow/widower.
5. Department/Branch/Section where employed.
6. Post held with ticket number or serial number if any.
7. Date of appointment:
8. Present address :
9. Permanent address:
Village  …….Thana……Sub-division……..Post Office…….District    ……..State
Place…….                                                           Signature/thumb impression of
Date…….                                                           the employed person
______________________________________________________________________
Declaration of witnesses
Fresh nomination signed/thumb impression before me
Name in full and full address                                          Signature of witnesses.
1 .                                                                                1 .
2.                                                                                 2.
Place………..
Date………..
______________________________________________________________________
Certificate y employer
Certified that the particulars of the above nomination have been verified and recorded in register of nominations in Form IV at serial number…….
Signature of the employer
Officer authorised
Designation
Name and address of the
mine or rubber stamp
thereof.
Place………….
Date………….
Acknowledgment of the employed person
Received the duplicate copy of the nomination in Form 11 filed by me and duly certified by the employer.
Signature of the employed person
Place………
Date ………
NOTE : Strike out the words and paragraphs not applicable.
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