New Form No.
-11 - Declaration Form
(To bt rttolned by the nn,,l,l~r for futurt rt/eumct)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees· Prov,~ent Fund, Schen,.,, 1952 (Parayr;,ph 34 & 5n &
Employocs· Pen~on Sr.hOme, 1995 (Paragraph 24)
(DeclaratlC\ri by 8 1,erson taking up employment In any establist>ment on which EPF Scheme, 1952 and/« EPS, 1995 Is appllcable)
. -Name of th e Membtir . . - · - - - --- - ·- - --·· - - - - - - - --- - - - -- - - -
!
2 ~T Fathe(s Nam£' l2( Spouse's Name O ·
_latr.___c\..ou~b~,- - ~
I '
(Please t1ck_~~~~•er is a~? 1cable) __ _ ___ _ __ _
.. . ..,() 0 ~lli.'._J
ti\!\_ \.-- \N\ __ _c.___mJ_J
,\ -.,
I Date of Birth: <Di), MM, yyyy l _LL:-_LQ_:_Loo 3
! Gender: (MalE/FemcilefTransgender) \ ::_..~ - -- - - ---j
5 I "larital Statu$ (Mamed/Unrnarried/W1dow/Widower/l)ivo~e ~) - - -1-- _Mme_____________ ~
1~ 6 l(a) Email ID: ·- - - - - - -- - --- --·- - -- - - - -·-·- - --- - - - ,-Q,-~~\~tf)a.t\ .C.ovn ~·
_ _ (bU-:,obile Ne .: _ _ 7 ~OQ 0_01 \ '2.-8 _
J 7 J Whether earlh!r a member or Employees' Provident Fund Sct erne, Ye
:_s_/ _
N_o_ _ _ _ _ _ _--l
- -- · !95_2
a Whether earlhir a member or Employees' Pension Scheme, 1395 - ·- - -----.;;;;;-N
_o__ ---- ---,
' Previous employment cletalls: [If Yes to 7 AND/OR 8 ,ibo_v_e--=J- t -- - - -- -- -
:
! a) Universal Accovnt Number:
b) Previous ?F Account Number:
9
c) Date or eo<~lroinprevicus erriploymenl~-( DD/MM/YYYY) -------_-------_--- -==~
' d) Scheme Cert,firnte Ne. (If Issued) --·
I - - - - -----,'
1-
!
r e)
·---
Pe,1s1on Payr1e11t Ord1?r (FPO) No . (if issued)
-- - - --
\ a) International Worker: · ----·- --
Yes/No
!'
' ___,
i
'' _____ J I
----
- -!
, b) If yes, state c:ountr, cf origin (!ndiaiName of ot:,er cour 1trt)
10 c)l'assport ~ --··- - - - - -···-·· .. - - - - --
r , -validity o' passport [(DD/ MM/YYYY) to (DD/t<iM/YYYY)J
-- -- -- -- -
- --- ---- -- -~
~ ails: (attach sell' dltested r.opie-; of following KYCs)
·-· --
11 : a) Bank Account No. & _IFS Code
... 5 o\ ao s 6 s1 '-! ruu_o~~61-~~
I b) AADHAR Numb>~r l.\o, C\ \1.C..\ ~ 3
-·-·
I c) Permanent Account NLJmber (PAN), if available
- - -- -· ---- ----- - - -----
C,_Q_r'\ Y C 6a S \ ~
UNiJERTAKING
true to the best of my knowlEdge.
1) Certified t! 1a: the parti::uiars are
2) I authorize EPFO lo use my Aadhar for verifiu1tion/aJthent1cal.ion/eKYC purpose for sen,ice delivery.
3) Kindly transf~r the funds ar.d service details, if applicable, frorn the previous PF account as declared above to the present P.f . Account.
(Toe transfer would be possible only if the identified KYC deta,1approved by previous employer has been verified by present employer
using his D1g1tal S111nature Certificate)
4) In case of changes in above details, the same wil' tJe intlmate,j to employer at the earliest.
Date:
Place; Signature of Member
DECLARATION BY PRESENT EMPLOYER
A. The ~n:iber Mr,JMs,/Mrs. . L\::\\.~.~. . . ..... has joined on \.S. :::.~ .:-:.7S,, and has been allotted PF Number
·········· ······""••J' ••······ ·· ·· .... ··· ·· ·· ·••
8. Jn case the person was earlier not a member of EPF Scheme, l952 and EPS, 1995:
{Post allotment of UAN) Toe UAN allotted for the member Is ............. ..............
• Please Tkk the Appropriate Option:
ltie KYC details of the above member in the 1JAN database
Ha\'e not been uploaded
Have been uploaded but nol approved
Have been uploaded and approved with DSC
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:
• Toe a'::>0ve PF Account number/UAN of the memhe- as mentioned in (A) above has been tagged with his/her LIAN/Previous
Memter ID as declared by member.
• Please Tick the Appropriate Option:•
c Toe 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 .
c· As the DS~ of establishment are not registered with EPFO, the member has been informed lo Rle physical daim (Form-
13) fOI' transfer of funds from his previous establ 1shment. ~ U ~~ hO dh.
Date: Signature of Emplcyer with Seal of Establishment
r
(FORM 2 REVISED)
NO~IINATION AND DECLARATIO N FORl\I FOR lJNEXEJ\·IPTI D!EXEI\IPTED ESTABLISHMENTS
Dedant1011 Mid J\'om11iation Fo1111 under the Employees P1·0,,dmWu1x!s and Employees Pension Schemes
(Paragraph JJ and 6 1 ( I ) of tbe Emp!o)=• Pnmdent Ftwd 3cheme H·J>52 and Paragraph 18 of tlie Employees
Pension Scheme 1995}
I . NAme (IN BWCK LETTERS)
l\'ame Father's f Httrb1111d's Name Surname
2 Date ofBirtb : _ _ _ __ _ __ 3 AccomJI No _ _ __ __ __
4 •sex _\iALEIFEMALE _ _ _ _ __ _ _ _ 5 Marital Stah1s
6. Address Pennaneutl Temporary · _ _ _ __ _ _ __ __ _ _ _ _ _ __ _ __ _ __ _ _ __ _ _
_
PART - A (EPF)
I hereby oominate the person(s)1cancel then01runation made by me pte,~ously :nici! oominate the persou(s) mentioned below
· U:· lhe Employees Provitll'Ul Fllllcl, in Che event of my de-dlh.
· t11e flU\OUll slamrtllg 10 WVci-ed,t
10 1'.'CetW
Jfthe nominee is minor
Nruueoflhe AddJes5 Nominee's Date of Totil amo1mt or share of name and addres5 of the
N01ninee (s) relationship \\ith Bi11h accumulations in iuard,an '1\-UO may receive
the member Pimident Funds lo be the amount during the
p,,id lo ""ch nominee minonty oflhe nomilll'<'
J '.' 3 4 5 6
.
+certified that J have no family as defwed in pam 2 (g) of the Employe~ P1m-idail Ftmd Schewe 1952 and should I
acqwre a family hercnftcr the above n ominr.tion sho1tld be d eemed a, cancelled.
• Certified that my .lather/mother is/are depeudt11I upon me.
Stnke out whichever 1s not apphcable Signature/or thumb uniress1on
of the subscriber
PART-(EPS)
Para IS
I hereby fumish below particulars of the members of my family who wmtld be eligible to receive Widow/Children Pension in the
eveot of my premanue de•lh m• =~ce.
s,: No Name & Address of the Family Member Age Relatiooship with the member
(l) (2) (3) (4)
Cl"lllfit•d that I have uo fimuly a, d,fmecl 111 parn 2 (m) uf u., E1upluy<e> '> Faiwly Peo:siou Scheme 1995 aud should I acc11une a
family hereafter I shall furrush Parbculars th ere on m the abo,·e fon::i.
l hereby nonumte the followmg person for rece1rn1g lhe moulldy mclow pension (adm1SS1ble under parn 16 2 (a) ( 1) & (11) m the
ewnl of my death "~!bout leav mg any eltgtble family member for recei,ing penston.
Name and Address of Dale of Bulb Relaltonsbtp w ith member
the nollUlec
Date _ _ _ _ _ __
Signature or thwnb uupre>Sion
of the subscnb~
- -- - - - -- - - - - - - -
CERlUICATEBY EMPLOYER
Cerhfied th2t Ou, abo\1! declombon and 1101runahon has bet'll . ,gned / th,unb tmp,es,..d btfore m ;, by S hn / SmtJ
~tiss Lo\,~ Q,uQo.~(l~ C'nO\)..~h,d~~ employedinmyesbblisbmentafterhelsb~has
read the entries / the entnes have been read over to him/her by rue and got confirmed byhillllber
Signature of lhe employer or otrer authorised officer of the
establishment
Place : ff\ \,\Y'f\ ba,
Name & 2ddre~ of the Factory/Establishment
Date : \ L\ ~ l\ .-z_ S
