m No. 11 (New) in Form re reference) For ; Declaratio ined by the Employer for fot Organization wen 34 & 87) (To be ret es’ Provident Fund PRovingNT FUNDS SCHEME, 1962 (PARAS? Employes THE EMPLOYEES: : THE EMPLOYEES PENSION SCHEME, 1995, (PARAGRAPH-24) I ANESTADLISHMENTON WHICH _E! se prowioent FuNo SoHE (cai BYAPERSON TASS ESF ELOVEES PENSION SOMENE EEE SHIH NSTRUCTIONS) nw _omo (ale iklalrla Bel TpZ] Ms. | MRS. | | maaTe | 2 ‘bireonece see Tee 7i7lelé 1A 8 3) FATHER'S Ya ye EA ZL yA H e 4)_ RELATIONSHIP IN RESPECT OF (3) ABOVE HUSBAND 5) ,Gevoer FEMALE | TRANSGENDER (PuEsseTIX) 6) Moonee (team) 2 PIONZIF \O Z2lololzl@lelnla 7 2) ematLio (Iraw) —[o “1 8 3) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEME, 1952? iicd (PLEASE TICK) ves“ NO IMETHER EARLIER A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995? (PLEASE Tick) Yes 7 | NO (8) & (8) ABOVEIS YE 'S, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAIL |F RESPONSE TOANY OR, B01 AT (40,11.842): Le Page 1 of 310) THe oeTAN eae ) 1 OFT UNITREAL ACCOUNT ‘en (URI) 08 rorvous Men 1D: “ Zio lola le 1s lo 171 PREMOUS PF MEMOIR ID iE ‘BION CODE | ‘Ornice COO stant b | 12) (aytesowpar ceRTTCATE ISATD FOR PREVIOUS HFLONIE oe ae as Wo “es rer oerasin 43 (A), 19:(0) #9190) 1A) DATE oF HT FOR PREVIOUS. MEMBER TD (DD/MMYYYY) cu, ens On UN OTEST?,—— aoa PPO RP Le TME REN TOL 19) ABE NS YES, nei Te) SSIMER We ROTA (IFES, PEASE MENTION NAME OF THE COUNTRY) TECHNICAL 2S, [oe oe | [a ‘WiDOW/ WIDOWER | DIVORCE TF YES, TICK THE CATEGORY LocoMOTIVE Visuat HEARING Page 2 of 3447) xvcoerans [RVC boca TFET Bak AccouN PRADA ERAN ROCOONT [ovecnirany) (GAIA ATO wv. PASSPORT Gua LAO 7 —| [pact Dane ENE [pawnetinee [| TecON RD : [Berea Bartow OD | BICC Hoi: FRE Covey RTORTORY YOU Randaton | ac necount NUMBER (ALONG TT ; a ey a Cano Nacanamnt AR HOWE AD Se ATTESTED POTOCOPES SET BocuMenTs HUSTEE LL SERTUNDER Ses a searara as a ove 61 10 THEOESTOF NY KNOMEDGEAN FELT [A LCERTIFY THAT ALL THE INFORMATION GN 5 teesse eer 70 usr HEWOER a ID SERVICE DETAILS IF APPLICABLE FROM InAs Ae me COmECTESEOF Ve ave ENSURED ME Sor gu REQUESTFOR TRANSER OTE wm “THE PREVIOUS ACCOUNT AS | DECLARED ABOVE TO THE [PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE FOSSIELE re PRerOO pey mncus ELON EEN ERT oer RY en peal SUNATURE CERTIICATE) oe irmruqumenromtraauc UM ans eI rs IGNATURE OF MEMBER GARATION OV PRESENT EMPLOYER oreo a at ND HAS BEEN ALLOTTED PF MEMBER Tl IAS JOINED ON penne “TE NENBER Mr, /MS. MIS. aaa EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995: (POSTALLOTMENT OF UAN) THE UAN ALLOTTED FOR THE MEMBER I PLEASE Tick THE APPROPRIATE OPTION. eee KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE Ny HAVE NOT BEEN UPLOADED \ Fh. HAVE BEEN UPLOADED BUT NOT APPROVED HAVE BEEN UPLOADED AND APPROVED WITH DSC C_ INCASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEVE, 1952 AND EPS, 199! “Tie ABOVE HEBER IO OFTHE MEMBER AS MENTIONED IN (A) ABOVE HAS BEEN TAGGED Wai His/HeR UAN/PREVIOU [MEMBER 1D AS DECLARED BY MEMBER. PLEASE TICK THE APPROPRIATE OPTION :- i 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. 13 AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT. DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISE Page 3 of 3