Form No.

11 (New)
Declaration Formn
(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 APERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES' PROVIDENT FUND SCHEME,
1952 AND/OR EMPLOYEES' PENSION SCHEME, 1995 1S APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)
1) NAME (TITLE)
MR. Ms. MRS. |k D D E E P
(PLEASE TIcK)

2) DATE OF BIRTH D

3) FATHER'S/ MR.
HuSBAND's NAME
SIA AMJIA V KU}MA R

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HuSBAND

(PLEASE TiK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MoBILE NUMBER
(IF ANY) 3

7) EMAIL ID (IF ANY) h h 3

m

8) WHETHER EARLIER AMEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME, 1952?

(PLEASE TIcK) YES NO
9) WHETHER EARLIER AMEMBER OF THE EMPLOYEESPENSION SCHEME, 1995?
(PLEASE TIcK) YES L NO
IFRESPONSE TO ANY OR BOTH OF (8) &(9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETATLS
AT (10,11&12):
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 A. PREVIOUS EMPLOYMENT DETATLS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF
MEMBER ID:
UAN
OR 83 |
PREVIOUs PF MEMBER ID
REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION AccoUNTNUMBER
Soo 214988 49
11) DATE OF EXIT FOR PREVIOUS D D M Y Y Y Y
MEMBER ID (DD/MM/Yn)

12) (A) IF SCHEME CERTIFHCATE ISSUED FOR

(B) IFPENSION PAYMENT ORDER (PPO) PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:
ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:
B. OTHER DETAILS

13) INTERNATIONAL WORKER YES No

(PLEASE TIa)
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 M M Y

To M M Y Y

14) EDUCATIONAL NON SENIOR

0LITERATE MATRIC PoST
TECHNICAL/
QUALIFICATION MATRIC SECONDARY GRADUATE
GRADUATE DocTOR
PROFESSIONAL
(PLEASE TICK)

15) MARITAL STATUS MARRIED UNMARRIED WIDOW/ WIDOWER DVORCEE

(PLEASE TICK)

16) SPECUALLY 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*
kldeel konay S0021498849
NPR/AADHAAR kultee kyma 223443l6 745
PERMANENT ACCOUNT
NUMBER (PAN) kuldeet Kmon LVGPk9377D
PASSPORT
DRIVING LICENCE
kuldee? kumoy I6-0- 203)
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NoTE: BANK AccoUNT NUMBER (ALONG WITH
ARE HOWEVER ADVISED TO PROVIDE ALL KYCDOCUMENTS
IFSC cODE) IS MANDATORY. YOU
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. INCASE, EARLIER AMEMBER OF EPF SCHEME, 1952
() IHAVE ENSURED THE CORRECTNESS OF MY UAN/
AND/OR EPS, 1995,
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR
PREVIOUS PF MEMBER ID.
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 THATI CAN SUBMIT MY NOMINATION FORM
THROUGH UAN BASED MEMBER PORTAL.

DATE:
PLACE:

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 AMEMBER 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 AMEMBER OF EPF SCHEME,
1952 AND EPS, 1995:
THE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN (A)
MEMBER ID AS DECLARED BY MEMBER.
ABOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIOUS
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
PHYSICAL CLAIM (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT. INFORMED To FILE
S

DATE:
SIGNATURE OF EMPLOYER WITH SEAL OF EsTABLISHMENT
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