Composite Declaration Form -11
(To be retained by the employer for future reference)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 and 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme,
1952 and /or EPS, 1995 is applicable)
1. Deepak Bohra
Name of the Member
Father’s Name (or) Spouse Name Uttamchand Bohra
2.
(Please Tick Appropriate Option)
3. Date of Birth: (DD/MM/YYYY) 06/03/1992
4. Gender: (Male / Female /Transgender) Male
5. Marital Status: (Married/ Unmarried/Widow/ Widower/ Divorcee) Unmarried
(a) Email ID: deepakbohra123@gmail.com
6.
(b) Mobile No: 9884056642
7. Present employment details: 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.: 400002706160019
DEUT0784PBC
(b) IFS Code of the branch:
8.
(c) AADHAR Number 540951184432
(d) Permanent Account Number (PAN), if available AHMPB5017D
9. Whether earlier a member of Employees' Provident Fund Scheme,1952 (Yes/No) YES
10. Whether earlier a member of Employees' Pension Scheme, 1995 (Yes/No) YES
Previous employment details: (if Yes to 9 AND/OR 10 above I - Un-exempted
Establishment Universal PF Date of Joining Scheme PPO Non-Contrib
Name and Account Account (DD/MM/YYYY) Date of exit Certificate Number utory Period
Address Number Number (DD/MM/YYYY) No. (if (if (NCP) Days
issued) issued
THINK AND PYBOM 24/07/2017 09/12/2024
LEARN 006067
11. PRIVATE 400000
LIMITED 15530
PHYSICSWALL UPALD2
AH LIMITED 108299
31/03/2025 03/05/2025
000002
9688
Previous employment details: (if Yes to 9 AND/OR 10 above) - For Exempted Trusts
Name and UAN Member Date of Joining Scheme Non-Contribu
Address of the EPS A/c (DD/MM/YYYY) Date of exit Certificate tory Period
Trust Number (DD/MM/YYYY) No. (if (NCP) Days
12.
issued)
13. (a) International Worker: (Yes/No) No
(b) If yes, state country of origin (India/Name of other country) India
(c) Passport No. T6209901
(d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)] 12/06/2019 to 11/06/2029
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.1
4) In case of changes in above details, the same will be intimated to employer at the earliest.
Date: 05-05-2025
Place: Chennai Signature of Member
DECLARATION BY PRESENT EMPLOYER
A. The member Mr. /Ms. /Mrs.......................................................................................... has
joined on………………………………and has been allotted PF
Number……………………………………….and
UAN……………………………………………..
B. In case the 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:
1
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.
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.
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
