Composite Declaration Form -11
(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 Shevak Kishore v
2 Father’s Name Spouse’s Name
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY) 09/10/2000
4 Gender: ( Male / Female /Transgender ) Male
5 Marital Status (Married /Unmarried /Widow/Widower/Divorcee) Single
(b) Mobile No: +91-7358120926
7 Present employment details:
Date of joining in the current establishment (DD/MM/YYYY)
8 KYC Details: (attach self attested copies of following KYCs)
a) Bank Account No.:
b) IFSC Code of the branch:
c) AADHAAR Number (12 Digit) 717180634267
d) Permanent Account Number (PAN), If available NPQPS2838N
9 Whether earlier a member of Employees" Provident Fund
Scheme ,1952 Yes No
10 Whether earlier a member of Employees" Pension Scheme ,1995
Yes No
11
Previous employment details: [If Yes to 9 AND/OR 10 above] - Un-exempted
Universal Scheme Non Contributory
Establishment PF Account Date of joining Date of exit PPO Number
Account Certificate No. Period
Name & Address Number (DD/MM/YYYY) (DD/MM/YYYY) (if issued)
Number (if issued) (NCP) Days
12
Previous employment details: [If Yes to 9 AND/OR 10 above] - For Exempted Trusts
Scheme Non Contributory
Name & Address of the Member EPS A/c Date of joining Date of exit
UAN Certificate No. Period
Trust Number (DD/MM/YYYY) (DD/MM/YYYY)
(if issued) (NCP) Days
a) International Worker:
Yes No
b) If Yes, State Country of Origin (India /Name of Other
Country)
13
c) Passport No
d) Validity of Passport (DD/MM/YYYY) to (DD/MM/YYYY)
UNDERTAKING
1) 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
Account*.
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 joined on and has been
allotted PF No. and UAN
B) In case 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
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:
• Please Tick the Appropriate Option
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.
The previous account of the member is not Aadhar verified and hence physical transfer form shall be initiated.
Date
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.
