Declaration Form
(To be retained by the Employer for future reference)
Employees’ Provident Fund Organization
THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES’ PENSION SCHEME, 1995 (PARAGRAPH-24)
DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES’ PROVIDENT FUND SCHEME,
1952 AND/OR EMPLOYEES’ PENSION SCHEME, 1995 IS APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)
1) NAME (TITLE) N I K H I L R A W A T
MR . MS. MRS.
(PLEASE TICK)
2) DATE OF BIRTH D D M M Y Y Y Y
2 7 1 2 1 9 8 6
3) FATHER’S/ MR . H E M A N T S I N G H R A W A T
HUSBAND’S NAME
4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND
(PLEASE TICK)
5) GENDER MALE FEMALE TRANSGENDER
(PLEASE TICK)
6) MOBILE NUMBER
(IF ANY) 9 7 1 6 7 6 0 1 2 5
7) EMAIL ID (IF ANY) N I K . R A W A T 1 2 3 @ G
M A I L . C O M
8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952?
(PLEASE TICK) Yes NO
*
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995?
(PLEASE TICK) Yes NO
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT (10,11&12):
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A. PREVIOUS EMPLOYMENT DETAILS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:
UAN 1 0 0 0 1 9 0 2 5 4 7 5
OR
PREVIOUS PF MEMBER ID REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER
11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y
MEMBER ID (DD/MM/YYYY)
1 3 0 2 2 0 2 4
12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:
B. OTHER DETAILS
13) INTERNATIONAL WORKER YES NO
(PLEASE TICK)
IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13(C):
13(A) COUNTRY OF ORIGIN (Please Tick)
INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)
13(B) PASSPORT NUMBER
13(C) PASSPORT VALID FROM
D D M M Y Y Y Y
To D D M M Y Y Y Y
14) EDUCATIONAL ILLITERATE
NON-
MATRIC
SENIOR
GRADUATE
POST
DOCTOR
TECHNICAL/
QUALIFICATION MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)
15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE
(PLEASE TICK)
16) SPECIALLY ABLED YES NO IF YES, TICK THE CATEGORY
(PLEASE TICK) LOCOMOTIVE VISUAL HEARING
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17) KYC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* NIKHIL RAWAT 50100083632588 IFSC Code HDFC0001360
NPR/AADHAAR NIKHIL RAWAT 574800147280
PERMANENT ACCOUNT
NUMBER (PAN) NIKHIL RAWAT AMMPR3082P
PASSPORT NIKHIL RAWAT
DRIVING LICENCE NIKHIL RAWAT
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO
AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.
C. UNDERTAKING:
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
B. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM
THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE
ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT
EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.
15-02-2024
DATE:
PLACE: GURUGRAM SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr./Ms./Mrs. ………………………….. HAS JOINED ON ............................. AND HAS BEEN ALLOTTED PF MEMBER ID
…………………………………………...
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 MEMBER ID 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
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