Declaration Form
Ecode
(To be retained by the Employer for future reference)
Employees' Provident Fund Organization
THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES' PENSION SCHEME, 1995 (PARAGRAPH-24)
DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES'
PROVIDENT FUND SCHEME, 1952 AND/OR EMPLOYEES' PENSION SCHEME, 1995 IS APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)
1) NAME
(TITLE) MR. MS. MRS. PRAMOD DWIVEDI
2) DATE OF BIRTH 21/07/1967
3) FATHER'S/ MR. Ram Avtar Dwivedi
HUSBAND NAME
4) RELATIONSHIP IN RESPECT OF (3) ABOVE Father
5) GENDER Male
6) MOBILE NUMBER 8604842481
7) EMAIL ID (IF ANY) VISHWESHDWIVEDI76@GMAIL.COM
8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME, 1952 ?
Yes
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES' PROVIDENT FUND SCHEME, 1995 ?
Yes
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS
EMPLOYMENT DETAILS AT (10,11&12):
A. PREVIOUS EMPLOYMENT DETAILS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:
UAN 101375439463
OR
PREVIOUS PF MEMBER ID REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER
11) DATE OF EXIT FOR PREVIOUS
MEMBER ID (DD/MM/YYYY)
12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN
SCHEME CERTIFICATE NUMBER:
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT,
THEN PPO NUMBER:
B. OTHER DETAILS
13) INTERNATIONAL WORKER No
IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13(C):
13(A) COUNTRY OF ORIGIN (Please Tick)
OTHER THAN INDIA (IF YES, PLEASE
INDIA
MENTION NAME OF THE COUNTRY)
Yes
13(B) PASSPORT NUMBER
13(C) PASSPORT VALID FROM
TO
14) EDUCATIONAL Under Graduate
QUALIFICATION
15) MARITAL STATUS Married
16) SPECIALLY ABLED No IF YES, CATEGORY
17) KYC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* Vishwesh Dwivedi 237201503651 ICIC0002372
NPR/AADHAAR PRAMOD DWIVEDI 327159482987
PAN Pramod Dwivedi AFQPD4108K
PASSPORT
DRIVING LICENCE
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS
MANDATORY. YOU ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE
WITH YOU IN ADDITION TO MANDATORY KYCS TO AVAIL BETTER SERVICES. SELF-ATTESTED
PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.
C. UNDERTAKING:
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
B. IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF
APPLICABLE FROM THE PREVIOUS 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).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.
This document is digitally acknowledged by PRAMOD
DWIVEDI on 16-09-2024 - 11:11:09 PM
PAN Number: AFQPD4108K
DATE: 14/09/2024 X Employee Signature
PLACE:
DECLARATION BY PRESENT EMPLOYER
A. THE MEMBER Mr. / Ms. / Mrs. HAS JOINED ON AND HAS BEEN ALLOTED
PF PF MEMBER ID .
B. IN CASE THE 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 MEMBER ID 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 (FORM-13) FOR TRANSFER OF FUNDS FROM HIS PREVIOUS
ESTABLISHMENT.
DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT
