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Composite Declaration Form -11

EMPLOYEES’ PROVIDENT FUND ORGANISATION

Employee’ Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees• Pension Scheme, l99S (Paragraph 24)

Name of the member DEEPAK C

Father Name CHOODESH B
2
Spouse’s Name

3 Date of Birth: ( DD / MM / YYYY ) 12/04/2002

4 Gender: (Male/Female/Transgender) Male
5 Marital Status: (Married/Unmarried/Widow/Widower/Divorcee) Unmarried
(a) Email ID:
6
(b} Mobile No.: 9535784591
Present employment details:
7 Date of joining in the current establishment (DD/MM/YYYY) 05/05/2025

KYC Details: (attach self attested copies of following KYCs)

a) Bank Account No. : 50100671043133
8
b) IFS Code of the branch: HDFC0000075
c) ADDHAR Number 882553838217
d) Permanent Account Number (PAN), if available GXSPD5600L
Whether earlier a member ofEmployees’ Provident Fund Scheme,
9 1952 Yes No
10 Whether earlier a member of Employees’ Pension Scheme, 1995 Yes No
Previous employment details: [if Yes to 9 And OR l0 Above] - Un-exempted
Establishment Universal PF Account Date of Date of exit Scheme PPO Number Non
Name & Address Account Number joining (DD/MM/ Certificate (if issued) Contributory
Number (DD/MM/ YYYY) No. (if Period
YYYY) issued (NCP) Days
Omega healthcare 102027282493 PYKRP00355530 23/12/2023 31/03/2025
000123992

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 A/c 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)

d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)]

 UNDERTAKING

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 PT. Account as I am an Aadhar verified employee in my previous PF Account.*
4) In use of changes in alive details, the same will be intimated to employer at the earliest.

Signature Of Member
Bengaluru

DECLARATION BY PRESENT EMPLOYER

A. The Member Mr/ Ms/ Mrs .........................................................................

DEEPAK C has joined on ......................,................
05/05/2025

Allotted PF No. .........,............................................................aml

PYKRP00355530000123992 L'AN.................................................................................................
102027282493

B. In case person was ‹earlier not a member of EPF Scheme, 1952 and UPS, 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/e-sign.

C. In case the person was earlier a member of I\PF Scheme, 1952 and
UPS, 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 a0d transfer request has been generated on portal
The previous Account of the member is not Aadhar verified and hence physical transfer from 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 employee’s arc
requested to file physical claim (Fomi-13) fa transfer of account from the previous establishment.
 FORM-I

NOMINATION AND DECLARATION FORM

(See rule 3)

1 Name of person making nomination Deepak C

(in block letters)

2 Father's/Husband's Name Choodesh B

3 Date of Birth 12/04/2002

4 Sex Male

5 Marital Status Single

#108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

6 Permanent Address

7 Temporary Address #108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below to receive any
amount due to me from the employer, in the event to my death.

If the
nominee is
minor,
name,
relationship
Total amount of
Nominee's and address
share of
Name of the relationship of the
Address Date of Birth accumulations in
nominee/nominees with the guardian
credit to be paid
member who may
to each nominee
receive the
amount
during the
minority of
nominee.
(1) (2) (3) (4) (5) (6)
Nirmala
#108/6/4
S near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76
Mother 28/10/1979 80%
Choodesh
#108/6/4
B near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76
Father 20/06/1974 20%

Certified that my father/mother is/are dependent upon me.

Signature of the employed person

 CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kum______________________________
Deepak employed in my establishment after he/she has read the entry/entries have
been read over to him/her by me and got confirmed by him / her.
for CARELON GLOBAL SOLUTIONS INDIA LLP

Authorized Signatory

Signature of the employer or other

authorized officer of the establishment and
Designation
M/s. CARELON GLOBAL SOLUTIONS INDIA LLP
L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ, Nagawara,
Bengaluru, 560045

Name and Address of the Factory/Establishment

Place: Bangluru and rubber stamp thereof.
Date :
 FORM – 2 (revised)
EMPLOYEES’ PROVIDENT FUND ORGANISATION

NOMINATION AND DECLARATION FORM

FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme.
(Paragraph 33 and 61 of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’ Pension Scheme, 1995)
1 Name (in Block Letters) 7 Permanent Address
Emp ID:__________ DEEPAK C
2 Father’s/Husband’s Name . (in case #108/6/4 near srinivas kalyan mantapa B
of married Women) CHOODESH B D C Road bilekahalli, banglore-76

3 Date of Birth 12/04/2025

Temporary Address
4 Sex Male
#108/6/4 near srinivas kalyan mantapa B
5 Marital Status Single D C Road bilekahalli, banglore-76

6 Account No PYKRP00355530000123992

PART-A (EPF)

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the

amount standing to my credit in the Employees’ Provident Fund, in the event of my death:

Name & Address of Nominee’s Date of Total amount or If the nominee is a minor,
Nominee/s Relationship Birth share of name relationship and address
with the accumulation in of the guardian who may
Member Provident Fund to be receive the amount during the
paid to each nominee minority of nominee
1 2 3 4 5
Nirmala S Mother 28/10/1979 100%

#108/6/4 near srinivas kalyan mantapa

B D C Road bilekahalli, banglore-76

2. *Certified that my father/mother is/are dependent upon me.

*Strike out whichever is not applicable. *Signature of the employed person

FOR OFFICE USE ONLY

Dt. of Joining E.P.F / /20 . . ENTRIES VERIFIED

Past Service ______________ Year

D.A S.S A.A.O
Date of Joining EPS / /20
 PART – B (EPS) Para 18

I hereby furnish below particulars of the members of my family who would be eligible to receive widow/widower/children Pension in event of
my death.

SI. No. Name of the family member Address Date of Birth Relationship with member
1 2 3 4 5
Nirmala s #108/6/4 near srinivas kalyan 28/10/1979 Mother
1. mantapa B D C Road bilekahalli,
Choodesh B banglore-76 20/06/1974 Father
2.

3.

4.

**Certified that I have no family, as defined in para 2(vii) of Employees’ Pension Scheme, 1995 and should I acquire a family hereafter I
shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly pension (admissible under para 16 (2) (g) (i) & (ii) the event of my death
without leaving any eligible family member for receiving pension.

Name & Address of the nominee Date of Birth Relationship with the member
Nirmala S 28/10/1979 Mother

#108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

Date:

*Strike out whichever is not applicable.

Signature of the subscriber.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri/Smt./Kum. employed
in my establishment after he/she has read the entries/entries have been read over to him/her by me and got confirmed by him/her.

Signature of the Employer or other authorised Officers of the Establishment

for Carelon Global Solutions India LLP

Authorized Signatory
Designation

Date:……………. Name & Address of the Factory/Establishment or Rubber Stamp thereof.

M/s. CARELON GLOBAL SOLUTIONS INDIA LLP

L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ,
Nagawara, Bengaluru, 560045
 FORM – F

[See Sub-Rule (1) of Rule 6]

NOMINATION
To

M/s. CARELON GLOBAL SOLUTIONS INDIA LLP

L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ, Nagawara,
Bengaluru, 560045

Deepak c
I Shri/smt./Kumari...................................................................................... whose particulars are given in the statement below, hereby nominate the
person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death
before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in
proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause (h) of Section 2 of the Payment
of gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section 2 of the said act.

4. (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the ________________ to the Controlling Authority in terms of the proviso
to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)
Name in full with full address of Relationship with the Age of Proportion by which the gratuity will
nominee(s) employee Nominee be shared
1. Nirmala S Mother 46 100%
#108/6/4 near srinivas kalyan mantapa B
D C Road bilekahalli, banglore-76

2.

3.

4.

Statement

1. Name of employee in full : Deepak C

2. Sex : Male
3. Religion : Hindu
4. Whether unmarried/married/widow/widower : Unmarried
5. Department / Branch/Section where employed : Bussiness operation
6. Post held with Ticket or Serial No., if any :
7. Date of appointment : 05/05/2025
8. Permanent address : #108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

Village _____________________ Thana _____________ Sub-division ______________

Post office __________________

560076 District ____________ State ___________________
Bengaluru Urban Karnataka
 Place : Bengaluru Signature of the employee
Date: 05/05/2025

Declaration
Declaration by
by witnesses
witnesses
Nomination
Nomination signed
signed // thumb-impressed
thumb-impressed before
before me.
me.

Name in full and full

address of witnesses Signature of Witnessea

1. Nirmala s

#108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

2.
Choodesh B

#108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

Place: Bengaluru
Date:

Certificate
Certificate by
by the
the employer
employer

Certified that the

Certified that the particulars
particulars of
of the
the above
above nomination
nomination have
have been
been verified
verified and
and recorded
recorded in
in this establishment.
this establishment.

Employer’s reference No.,

Employer’s reference No., if
if any.
any. for Carelon Global Solutions India LLP

Authorized
Authorized Signatory
Signatory
Signature
Signature of
of the
the employer
employer // officer
officer authorized
authorized
Designation
Designation
M/s. CARELON GLOBAL SOLUTIONS INDIA LLP
L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ, Nagawara,
Bengaluru, 560045
Name & Address of the establishment or
Rubber-stamp thereof
Acknowledgment
Acknowledgment by
by the employee
the employee

Received the
Received the duplicate
duplicate copy
copy of
of nomination
nomination in
in Form
Form `F’
`F’ filed
filed by
by me
me and
and duly
duly certified
certified by
by the
the employer
employer

Date: 05/05/2025
Date: Signature of the employee

Note : Strike out the words/paragraphs not applicable

 Statutory requirement

FORM `Q'
(See Rule 24 (9A)
Appointment Order
1. Name and Address of the Establishment : M/s. CARELON GLOBAL SOLUTIONS INDIA LLP
L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ, Nagawara, Bengaluru, 560045
M/s. CARELON GLOBAL SOLUTIONS INDIA LLP
2. Name and Address of the Employer :
L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ, Nagawara, Bengaluru, 560045

3. Name of the Employee : Deepak c

4. His / Her Postal Address : #108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

5 His / Her Permanent Address : #108/6/4 near srinivas kalyan mantapa B D C Road bilekahalli, banglore-76

6. Father's / Husband's Name : Choodesh B

7. Date of Birth : 12/04/2002

8. Date of His / Her entry in to employment : 05/05/2025

9. Designation : Claims Associate jr

10. Nature of work entrusted to him :

11. His / Her serial number in the :

Register of Employment (Muster Roll)
12. Rates of wages payable to him / her : 275000

i) Basic :
ii) VDA : - N.A -
iii) Other Allowances if any :

-----------------
TOTAL :
275,000.00
-----------------
for Carelon Global Solutions India LLP

Authorized Signatory
Signature of the Employer

Place : Bengaluru M/s. CARELON GLOBAL SOLUTIONS INDIA LLP

Date : L1 Banyan, Floors 6-10, Outer Ring Road,
Manyata Embassy Business Park SEZ, Nagawara, Bengaluru, 560045

Acknowledgement by employee Seal of the establishment

with date and Signature
05/05/2025
 The Telangana Shops & Establishments Rules, 1990
FORM XXVI
[ See Rule -30]
Letter of Appointment

Name and address of the establishment: Passport size

M/s. Carelon Global Solutions India LLP
H-09 Building, Avance Business Hub, photo of the
Survey No. 30(P), Serilingampalli, employee duly
Hyderabad, Telangana, India – 500019 attested by the
employee

Name and address of the employer:

Mr. MOSUR KRISHNAMOORTHY SAISEKAR
Manyata Embassy Business Park (SEZ)
L1 Banyan, Floors 6-10, Outer Ring Road, Nagawara Hobli,
Bangalore 560 045

Registration No: VSEZ/TNSE-113/2021

* Sri/ Smt/ Kumari Name of the employee Deepak c

* Son/ Wife / Daughter of Please mention

*Aged ___ Date of Birth___________ (mm/dd/yyyy) is appointed as

1. (Describe here the nature of appointment) _________________ in this Establishment with effect from
in the scale of pay of Rs.
2. His /her scale of pay/ rate of increment in wages (insert the period) shall be

3. * He / She will draw a total ______________ Per Day / Week / Month composed of the following namely :

(i) * Basic Pay _______

(ii) Dearness Allowance

(iii) * Other Allowances _______

* Signature of the Employer

To
Sri / Smt. / Kumari ________________
( here enter full address of the employee).

Copy to :- The Inspector for records.