UfTAR 3!
HAR GRAf,ilN BAIIIK
UEAD OITICE' TGLAMBAGE CEOWK
MI'ZAFFARPI'& BIHAR, 842(M
lsgonsoted By:: Central Bank of lndla )
a 22;S141(D). 2257918 Fax:d0521)2243088
fr-El In CaPitai letters;
Fathers / Husband Name
ItffiName
ffiook, Palr card & Aadhaar card'
Signarure of Candidate
New torm No.'11 - Derlaraiion Fofm
tlo be ,.taiaed by abe emplayar lo, latura ftlrr.nce)
SMPIOYE!S' PROVIDII.II FUND ORGANISATION
Emplayeee' Po$d6.1Folldt S.no(n!, 1052 (ParsqBph 3a & 54 n
EmDloyosi' Psrslon Sch€mq 10gS {pa&!.aph ?t)
{Dedaratlon by r t)sr3on iaking op omployaeol ln ary oslalish4lBdt on which EPf Sdlgme. ,952 3td lor EPS, l9S5 k aPpllc.ble}
1
lim*md-or t-ne ne-&;i
2. Fathe/s Name f] Spouse's Name n
{Please tick whiche\,o. is applicable)
3. Date of Elrti: { DD / Mi, / YYYY }
4 Gender: (MalelFemitleftransgender)
-
r"rTifiiii*ui orii*alUnnaiiL-i:lWioowlwiiiorerluvorce;l
6 (a) EmaillDi
ahl M.rbilo Nc-:
7 wt *tii earti:, a memb€r ot Enlployees' Provident Fund scl€me, Yss / No
1952
I wh€ther earlier a member ol Employee{ Pension Scheme, Yes I No
Frevious emptoynrert details: [ifYer to 7 A'{D/OR 8 aboval
a) Unrve6alAcmrntNumber:
b) F.evious qf Ac(ouni Numbe.l
I e{rt frorrl pre!ious ernPloYment:
dl Scheme certificate No. (if issued)
*--
6 Pen;6n l'ayr'1ern6;de, fei:oi rio. tii':sueot --
ai IntemationalWorker: Yes I No
6 iiies, sti:rte munty ol origin (India/Name ot other country)
10
ct lo
Posspott
;r-,6riaiii cr p;airi( (DDlMMnYnj tolDD/Mr'{,,vVWii-*
(yC Oetalts: (attach self attested eopies ol folhwlng KYG)
'11 ac{o,,nlr,il & lis cix6--
"l--6irii
b) MDHAR llurnbBr
;i;ermadnAra;i;;itNum#$ANI?;GGblA*'*'
UNoEnraKNc
1l C€rt,fied ttar" lhe particulars are t.ue to the beit oF my kno$'l€d$e'
purpose fqr serylc€ delivery.
2l I airihonz€ IPFC to uss fiy Aadhar fo. veriication/at$entic?llor/eKYc
servi(€ detallt, it applicable, fror{ the previous pF account as declnred above lO the present P t' Aecount'
3) itndty tran:ler tne tuncts and
wrified by present ernploycr
lrla rrnrru. *nrr,: na losgble only if the ideatlfled NYc detail approved by prevlo[s employer has bem
usi g hie oigilal Shnature Certificate)
In ci5e ol rirang*s ir abovc details, the saoe 'dill be intinaio' to employer at lhe earliesl
Drt€;
Srgnature ot Memb€r
Phcel
oEcLaRlllo!-ill8I:S:lglls8
The m?mber Mr.llrs./l'1.t. has loined on "'" " '" '"" " and has been allotted PF
'tumb€r
ln qa6e th€ p€rson was earlier not a member of fPF Schelne, 195? and €pS, 19951
. (Po't itllotmrnt of UAN) The UAN alloiled for the mefiber i5 " '
. Pte.ts Tick the Appropdato Option:
Tle lffc detlils of lhe above flleinber in the 'JAN dahbase
a. Ha\'e not $een upload€d
i Ha\€ been uploaded but nal lpp.oved
i Hale been uDloaded and app,oved $ith DSC
' cas€
ln lhe perlon wat earlrer a meober of EPF S(heme, 1952 and €pS, 1995i
;-* il;;u i;r i&ount numlxrlUAN of the memhe. as menlioned in (A) aiove has been tnqged with hls/her tlAN/Prevlous
.i:-' M€.ntet tD as de(lar€d by membet.
/t*i" . pleas*
- Tlck the Appropriato Optlor:'
l. ,,t,"-rvc o"t il, oi *i uaoue memo* inpodal the UAN databate hava b0gn approved with Di(ital sirnatute Cenificate
and
i .." i, lransier r€qlest has bQer generated on
r.. As t|le OSC of estaUfisr,rei,r are na iediitend rvith EPFO, ihe {Remb€r has btrrn info.tned to llle physical ddm (Form'
prevlous
:3) lor uansf€r of funda t.om his estnbrrshment'
Signsture of e$p!o/et with seal of f*nb'ishment
(FOR M 2 REVISED}
UNEXE PTED/EXE M PTED ESTABI'ISHMENTS
MlNAT]ON AND DECLARATION EORM TOR
M
NO
Providenl Eunds and EtrrploYees lension schemeg
Declalalron and Nominaiion rolm under ihe Enployees
Eund Scn^eme 1952 and Paragaph 18 of ihe EmploYees
(Palag:aPh 33 and 61 11) ot the umpLoyees Provideni
Pension scheme 19951
1. Name 1IN BLOCK I,ETTERS) i
Fathels i ltusband's Name
2. Daie of Biah: 3 Accoun! No'
5. M alital Siatus
4. *Sex I M ALE/EEM ALE:
6 Add,ess Permanent iTemPora!Y I
PART - A IEPE)
]helebvnominalethepelsonls)]cancelthenoninationnadebymepleuous]Yandnominale.lhepelsonlS]
a""'t''
iJ'!llir',iii" irJi,r'i" ,r'," i"
u*r"v*',n'"ia*' *?a' "*" "r 'v
"*","i ^v"'"ai, " 'n" ,
]f lhe nominee is ninor
Toial anount oi share o; .ane and addiess of the
accumulalions in gualdian who may leceive
Piovident Eunds io be ihe anouni duling ihe
paid to each noninee minoiity ol lhe noninee
should I
of lhe Employeer ?loudeni Euncl Scheme 1952 and
*.aiiri.d ihat t have no famrLy as delLned In pala 2 lg)
rominaL-on shou dbe deemed a'3 carc"-led'
r,":"*i", ,re above
""-- " "-,".:i,
* cerrii:ea tnat my tather/noihel is/ale dependent upon me
Signatule/o! thumb impress!on
sti,ke ou: whichevel is nol applicabLe oi lhe subscribel
PART' 1EPSI
Pa:a 18
Pension in ihe
., O*i,, * would be ehgrble !o leceive wjdowjchildren
he:eb, iurnrh beLow pa::rculars of ihe nembes
o!
i
evenr o: my plenaiule deaih in sen'lce
ReLaiionshiP qith ihe rnetnbel
Name & Address of the Eanily M enbe!
Sr, No
(3) {4)
1lt \2\
.t
I
should t acquire a
- ceflified ihat I have no fam:ly as detined in para 2 (vri) ol lhe EnployeeJs Fanily Pension schem€ 1995 and
' family hereatier l shall lumish Padiculals lhere on in the above lolm'
(admlssible under pala 16 2 {a) (il & {ii) in lhe
I hereby nornjnare ri]e loltowing perso! tor receivinq the nonihiy widow pension
event oi ny dealh withoul leaving any eligible fanily menber fo! leceiving Pension'
Name and Addless ol Dare of Bi$h Relalionship irith menbel
Signature or thumb implession
CERTIEICATE BY EMP],OYER
ce ified thar rhe above declaation and nominatlon has been signed / thunb impressed belole me by shli / sn!/
enployed in rny eslablishnent afie! hehhe has
.ead ibe entries / the enilies have been lead over io hiin/her by ne and got confLlmed by him/heI'
Signaiu.e ol lhe employel o! other authorised officer oI ihe
establishmeni
Place I
Name & ad&ess of the Eactorv /Establishmeni
''l: .
