Form-11 (New) - Declaration Form
(To be retained by the employer for future reference)
EMPLOYEES` PROVIDENT FUND ORGNIZATION
Employees provident Fund 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 ( in capital letter)
2 Father`s/Husband`s name
3 Date of birth
4 Gender (Male/Female/Transgender)
Marital status (Married/ unmarried/
5
widow/ widower/ divorce)
a) Email ID :……………………….
6
b) Mobile No…………………
Whether earlier a member of EPF Scheme,
7
1952 ( Yes/No)
Whether earlier a member of EPS Scheme,
8
1995 ( Yes/No)
Detail of previos establishment:
A) UAN
B) Previous PF account No.
9
C) Date of exit from previous employment
D) Scheme certificate No. ,If issued
E) PPO No., if issued
a) You are international worker, please
mension Name of country
10
b) Passport No. & Date of validity
a) Bank A/c No. & IFC ( cancelled cheque
provide)
11 b)Aadhar No. ( Copy of Aadhar provide)
c) PAN (Copy provide)
UNDERTAKING
1 I certtified that all the given above informations and documents are best of my knowledg & belief.
2 I authorise EPFO to use my Aadhar for verification/authentication/eKYC purpose for service delivery.
3
Kindly transfer the Fund and service details, if applicable from the previous PF account as declared above to the
present employer.
4 In case of change in above details, the same will be intimated to employer at the ealriest.
Date:
Place: Signature of Member
DECLARATION BY PRESENT EMPLOYER
The employee Mr./Ms./Mrs ………….................. …….s/o,d/o,w/o Sh …………...........……………….. has appointed
A on…….. ….................……..on post…………………….and his PF/EPS number has been alloted vide
UAN………............……….………..& PF a/c No……...............…….
B In case the person was earlier not a member of EPF Scheme, 1952 and EPS 1995:
* (Post allotment of UAN) The UAN allotment of member is :
* Please tick the appropriate Option:
The KYC Details of 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 No/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 appropraite option:
The KYC details of above member in the UAN database have been approved with Digital Signature certificate
and trasfer 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
Place:
