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Employees Provident Fund Organization: (To Be Retained by The Employer For Future Reference)

This document is a declaration form for a new employee, Nitesh Singh, joining an establishment covered by the Employees' Provident Fund Organization. It collects personal details like name, date of birth, gender, marital status, contact information, and previous PF account details if applicable. It includes an undertaking by the employee to authorize the use of Aadhaar for verification and allow transfer of previous PF funds. The employer declares that Nitesh Singh has joined and been allotted a PF number, and indicates whether his KYC details have been uploaded and approved in the UAN database.

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113 views1 page

Employees Provident Fund Organization: (To Be Retained by The Employer For Future Reference)

This document is a declaration form for a new employee, Nitesh Singh, joining an establishment covered by the Employees' Provident Fund Organization. It collects personal details like name, date of birth, gender, marital status, contact information, and previous PF account details if applicable. It includes an undertaking by the employee to authorize the use of Aadhaar for verification and allow transfer of previous PF funds. The employer declares that Nitesh Singh has joined and been allotted a PF number, and indicates whether his KYC details have been uploaded and approved in the UAN database.

Uploaded by

Yash Sells
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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New Form No.

11- Declaration Form


(To be retained by the employer for future reference)

EMPLOYEES PROVIDENT FUND ORGANIZATION


Employees provident funds 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 end /of EPS1995 is applicable)

1 Name of the member NITESH SINGH


2 Father’s Name ( ) Spouse’s Name ( )
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY) 0 8 0 8 1 9 9 8

4 Gender: ( Male / Female /Transgender ) Male


5 Marital Status (Married /Unmarried /Widow/Widower/Divorcee)
6 (a) Email ID: [email protected]

(b) Mobile No: 7611821150


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
Previous Employment Details - (If Yes to 7 AND /OR 8 Above)
a) Universal Account Number (UAN)
b) Previous PF a/c No
9 c) Date of exit from previous employment (DD/MM/YYYY)
d) Scheme Certificate No (if Issued)
e) Pension Payment Order (PPO) No. (If Issued)
a) International Worker: Yes No
b) If Yes, State Country of Origin (India /Name of Other Country)
10
c) Passport No
d) Validity of Passport (DD/MM/YYYY) to (DD/MM/YYYY) To
KYC Details: (Attach Self attested copies of following KYCs)
a) Bank Account No. & IFSC code
11
b) AADHAAR Number (12 Digit) 918171979154

c) Permanent Account Number (PAN), If available LHLPS9655J


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, 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 using his digital signature certificate)
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date:
Place Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member Mr./Ms./Mrs ......................................................has
NITESH SINGH 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

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