EMPLOYEES PROVIDENT FUND ORGANIZATION
Employees provident funds scheme, 1952 (paragraph 34 & 57) &
Employees pension scheme 1995 (paragraph 24) New Form No.11- Declaration Form
(To be retained by the employer for future reference)
Emp Code: This field will be blank
Company Name: SpringRole India Pvt Ltd
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of EPS1995 is applicable)
1 Name of the member Full name (eg: Jane Doe)
2 Father’s Name ( ) Spouse’s Name ( ) Full name ( eg: John Doe)(ticket father/
(Please Tick Whichever Is Applicable) spouse)
3 Date of Birth (DD/MM/YYYY) DD MM YYYY
4 Gender: ( male / Female /Transgender ) As applicable
5 Marital Status (married /Unmarried /widow/divorce) As applicable
6 (a)Email ID: Personal Email ID
(b)Mobile No: Mobile number that is linked to your aadhar
card.
7* Whether earlier a member of Employees ‘provident Fund Scheme 1952 Yes ▢ No ▢
8* Whether earlier a member of Employees ‘Pension Scheme ,1995 Yes ▢No ▢
9 If response to any or both of (7) & (8) above is yes. MANDATORY FILL UP THE (COLUMN 9)
a) Universal Account Number(UAN) LEAVE BLANK
b) Previous PF a/c No
AP HYD EST.CODE EXTN PF.NO
c) Date of exit from previous employment (DD/MM/YYY)
d) Scheme Certificate No (if Issued ) LEAVE BLANK
e) Pension Payment Order (PPO)No (if Issued)
10 a) International Worker: Yes ▢ No ▢
b) If Yes , State Country Of Origin (India /Name of Other Country) LEAVE BLANK
c) Passport No
d) Validity Of Passport (DD/MM/YYY) to(DD/MM/YYY)
11 KYC Details: (attach Self attested copies of following KYCs) **
a) Bank Account No .& IFS code XXXXXXX IFSC CODE XXXXX
b) AADHAR Number (12 Digit) As applicable
c) Permanent Account Number (PAN),If available As applicable
UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge
2) I authorize EPFO to use my Aadhar for verification / e KYC purpose for service delivery
3) Kindly transfer the funds and service details, if applicable if applicable, from the previous PF 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
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date: FILL AS APPLICABLE
Place: FILL AS APPLICABLE
PLEASE SIGN HERE
Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member Mr./Ms./Mrs ………………..has joined on …………….and has been allotted PF Number……………………………….
B) In case 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 PF account number /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 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 (Form13) for transfer
of funds from his previous establishment.
Date Signature of Employer With seal of Establishment
