New Form : 11 - Declaration Form
(To be retained by the employer for future reference)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)
1. Name of Member (Aadhar Name) Solanki Kalpesh Ashokbhai
2. Father's Name Spouse's Name Solanki Ashokbhai Maganlal
(Please tick whichever applicable)
3. Date of Birth (dd/mm/yyyy) 15-March-1989
4. Gender (Male / Female / Transgender) Male
5. Marital Status ? (Single/Married/Widow/Widower/Divorcee) Single
(a) eMail ID kalpesh.engg0@gmail.com
6.
(b) Mobile No (Aadhar Registered) 9099920176
Whether earlier member of the Employee's Provident Fund
7. Yes / No
Scheme, 1952 ?
Whether earlier member of the Employee's Pension
8. Yes / No
Scheme, 1995 ?
Previous Employment details ? (If Yes, 7 & 8 details above) 100632096383
a) Universal Account Number (UAN)
b) Previous PF Account Number VD/BRD/21007/608961
9.
c) Date of Exit from previous Employment ? (dd/mm/yyyy) 13/May/2024
d) Scheme Certificate No (If issued)
e) Pension Payment Order (PPO) (If issued)
a) International Worker No
b) If Yes, state country of origin (name of other country)
10.
c) Passport No. T7607088
d) Validity of passport (dd/mm/yyyy) to (dd/mm/yyyy) 22/08/2019 to 21/08/2029
KYC Details : (attach self attested copies of following KYC's) Must Enclose Scan copy for the following documents
a) Bank Account No. & IFS Code 50100198862882 IFSC: HDFC0000147
11.
b) AADHAR Number 672972646463
c) Permanent AccountFirst
First EPF Member
Number (PAN), If available
Employment EPF BTLPS5134A
Are you EPF Member If Yes, EPF Amount
After Sep 2014 earned
If Yes, EPS (Pension)
EPS (Pension) Amount
Enrolled Date Wages before 01/09/2014 Withdrawn? Amount Withdrawn?
12. Withdrawn before Join
current Employer?
01/10/2015 No No No No
UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge
2) I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
3) Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to the present PF 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
4) In case of changes in above details, the same will be intimated to employer at the earliest.
Date : 03-06-2024
Place: Signature of Member
Kalpesh Solanki
Gurugram
DECLARATION BY PRESENT EMPLOYER
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 Scheme, 1952 and EPS, 1995: ((Post allotment of UAN) The UAN allotted or the member is)
Please Tick the Appropriate 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 member of EPF Scheme, 1952 and EPS 1995.
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 : Signate of Employer with Seal of Establishment
