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Composite Declaration Form -11

(To be retained by the employer for future reference)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking op employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995 is applicable)

I Name of the member SANTHAPURI SUNIL KUMAR

2
Father's Name D
Tick
SANTHAPURI GOPALA RAO
Spouse's Name
D
3 Date ofBirth: ( DD/ MM I YYYY ) 15/07/1989
4 Gender: (Male/Femaleffransgender) Male
5 Marital Status: (Married/U nmarried/W idow/W idower/Divorcee) Unmarried
(a) Email ID:
[email protected]
6
(b) Mobile No.: 9123XXXX45
Present employment details:
7 Date of joining in the current establishment (DD/MM/YYYY) 25/09/2017
KYC Details: (attach selfattested copies of following KYCs) Attach xerox copies of KYC documents
a) Bank Account No. : Bank A/C Number
8 b) IFS Code of the branch: IFSC code of bank
c) AADHAR Number Aadhar number of the member
d) Permanent Account Number (PAN), if available PAN number of the member
Whether earlier a member of Employees' Provident Fund Scheme, Yes/No
9
1952 Tick Yes Or No
10 Whether earlier a member of Employees' Pension Scheme, 1995 Tick Yes Or No Yes/No
Previous employment details: (if Yes to 9 AND/OR 10 above I - Un-exempted In case employee already has UAN number
then fill this.
Establishment Universal PF Account Date of joining Date of exit Scheme PPONumber Non
Name & Address Account Number (DD/MM/ (DD/MM/ Certificate (if issued) Contributory
Number YYYY) YYYY) No. (if Period
issued (NCP) Days

Previous UAN DOJ DOJ

11 Previous
establishment number in in
PF
name of previous previous - - -
number
employee company company

Previous employment details: (if Yes to 9 AND/OR 10 above) - For Exempted Trusts

Name & Address of the Trust UAN Member Date of Date of exit Scheme Non
EPS Ale joining (DD/MM/ Certificate Contributory
Number (DD/MM/ YYYY) No. (if Period (NCP)
YYYY) issued Days
12

a) International Worker: Yes /No

13 b) If yes, state country of origin (India/Name of other country) -

c) Passport No.
-
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)] -
 UNDERTAKJNG

I) Certified that the particulars are true to the best of my knowledge.

2) I authorize EPFO to use my Aadhar for verification/authentication/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 as I am an Aadhar verified employee in my previous PF Accounl *
4) In case of changes in above details, the same will be intimated to employer at the earliesl

25-09-2017 Signature of the employee

Date:
Place: Hyderabad Signature of Member

DECLARATION BY PRESENT EMPLOYER

A.
Santhapuri Sunil Kumar 25/09/2017
The member Mr/Ms/Mrs ......................................................................... has joined on ......................................... and has been

New PF Number
allotted PF No....................................................................... UAN Number
and UAN ................................................................................................ .

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
• Please Tick the Appropriate Option:
The KYC details of the above member in the UAN database If employee has no previous UAN number
D Have not been uploaded then fill this part.
D Have been uploaded but not approved
D Have been uploaded and approved with DSC/e-sign.

C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:
If employee has already UAN number then
• Please Tick the Appropriate Option:- fill this part
0 The KYC details of the above member in the UAN database have been approved with E-sign/Digital Signature
Certificate and transfer request has been generated on portal.
D The previous Account of the member is not Aadhar verified and hence physical transfer form shall be initiated.

Employer Signature
Date: 25/09/2017 Signature of Employer with Seal of
Establishment

*Auto transfer of previous PF account would be possible in respect of Aadhar verified employees only. Other employees are requested to
file physical claim (Form-13) for transfer of account from the previous establishment.