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)
MR. MS. MRS
(PLEASE TICK)
2) Date of Birth D D M M Y Y Y Y
3)
FATHER’S /
HUSBAND’S NAME
4) RELATIONSHIP IN RESPECT OF (3)
FATHER HUSBAND
ABOVE
(PLEASE TICK)
5) GENDER MALE FEMALE TRANSGENDER
(PLEASE TICK)
6) MOBILE NO (IF ANY)
7) EMAIL ID (IF ANY)
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
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)
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 SENIOR POST TECHNICAL/
ILLITERATE NONMATRIC MATRIC GRADUATE
QUALIFICATION SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)
15) MARITAL MARRIED UNMARRIED WIDOW/ DIVORCEE
STATUS WIDOWER
(PLEASE TICK)
16) SPECIALLY YES NO
IF YES, TICK THE CATEGORY
ABLED
(PLEASE TICK) LOCOMOTIVE VISUAL HEARING
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17) KYC DETAILS KYC DOCUMENTS TYPE NAME AS ON KYC DOCUMENT NUMBER IFSC CODE
BANK ACCOUNT -1*
NPR /AADHAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT
DRIVING LICENCE
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 MEMBER OF EPF SCHEME, 1952 AND / OR EPS, 1995,
I. I HAVE ENSURED THE CORRETNESS 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 PF 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.
DATE :
PLACE : 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 / OR 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 / OR EPS, 1995:
• THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED (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 DATEBASE HAVE BEEN APPROVED WITH DIGITAL SIGNATURE
CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL.3
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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