New Form No.
-11 - Declaration For
reference)
be retolned by the employer for future
o
EMPLOYEES' PROVIIENT FUND ORGANISATION
Employoes' Provident Funds Bcheme, 1952 (Parngraph 34 & 57) 8&
Empioyoos Pansion Scheme, 1995 (Paragraph 24)
(Decl
y A person taking up employment in any oslablishment on which EPF Scheme. 1962 and lor EPS, 1995 is P
Name of the member
KUmAR
P: A TH
2 Father's Name Spouse's Name
pouAnwI SA M
(Please tick whichever is applicable)
Date of Birth: (DO MMIYYYY) 3 5 - 20oo
Gender: (Male/Female/Transgender)
male
Marital Status (Mamied/Unmarried/Widow/Widower/Divorce)
To
NO
6 )Email 1D: nK 30 10T aT
6Mobile No.: 3 8313 3
Whether earlier a member of Employees' Provident Fund Scheme, Yes / No
1952
Whether earlier a member of Employees' Pension Scheme, 1995 Yes / Ne
Previous employment details: [if Yes to 7 AND/OR 8 above]
a) Universal Account Number:
b) Previous PF Account Number:
c)Date of exit from previous employment: (DD/MM/YYYY)
d) Scheme Certficate No. (if issued)
e)Pension Payment Order (PPO) No. (if issued)
a) International Worker: Yes/ No
b) f yes, state country of origin (India/Name of other country)
10 c)Passport No.
d)Validity of passport [(DD/MM/YYY) to (DD/MM/YYYY)]
KYCDetails: (attach setf attested copies of following KYC)
11 a) Bank Account No. & IFS Code 5215 500o0T3022
KRLo0el12-
b) AADHAR Number 2502 q2s 79b2
c)Permanent Account Number (PAN), if available
G Hyep3SHsB-
UNDERTAKING
) Certified that the particulars are true to the best of my knowledge.
2) I authonze EPFO to use my Aadhar for verfication/authenticalion/eKYC purpose for service delivery.
3 Kindly transier the funds and service details, if applicable, frorn the previous PF account as dedared above to the present P.E. ACCOunt.
(The transfer would be possble only if the identfried KYC detali approved by previous employer has been verified by present employer
using his Digital Signature Certificate)
4) In case oft changes in above details, the same will beintimate to employer at the eariest.
Date
Place: Signature of Member
DECLARATION BY PRESENTEMPLOYE
A. The member Mr./Ms/Mrs. ** **.-***************** has JOined on ******.***..and has been allotted PF Number
B. In case the person was earlier not a member of EPF Schene, 1952 and EPS, 1995
(Post allotment of UAN) The UAN allotted for Ue member is.
Please Tick the Approprlate Option:
The KYC details of the above member in the JAN 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 nember of EPF Scheme, 1952 and EPS, 1995:
The aove PF Account nurnber/UAN of the menlver as mentioned in (A) above has been tagged with his/her UAN/Previous
Memter 1D as declared by member.
Please Tick the Appropriate Option
C 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 porta
As the DSC of establishment are not registered with EPFO, the rnember has been informed to file pthysical slayh Fom-
13) for transfer of funds from his previous estabiisthment
Date Sighature of Employer with Seal of Establishment
