New Form No.
11- Declaration Form
reference)
(To be retained by the employer for future
EMPLOYEESPROVDENT FUND ORGANIZATION Emp Code:
Employees provident funds sche me, 1952 (paragraph 34 & 57) &
Employees pension scheme l1995 (paragraph 24) Company:
(Declaraion by a person taking up employment in any establishment on which EPF Scheme, 1952 end /of EPS 1995 is applicable)
Name of the member
2 Father's Name ( Spouse's Name ( )
(Please Tick Whchever Is Applicable))
Date of Brth (DD MMYYYY
2 OM
4
Gender (mte Female Transgender )
Mantal Status (marned Unmatried widow/divorcc)
q)Email lD:
Moble No.
W'hether earlicr a member of Employecs 'provident Fund Scheme 1952 Yes No
Whether earlier a menber of Employces'Pension Scheme ,1995 Yes No
If response to any or both of (7) & (8) above is yes. MANDATORY FILLUP THE (COLUMN 9)
Universal Account Number(UAN)
b) Previous PF a'e No Ar HYD EST.CODE EXTN PF NO.
Date of exit from previous employment (DD/MM/YYY)
d) Scheme Certificate No (if Issued )
e) Pension Payment Order (PPO)No (if Issued)
a International Worker: Yes No
10 b If Yes, State Country Of Origin (india /Name of Other Country)
c) Passport No
Validity Of Passport (DDMMYYY) to(DDIMM/YYY)
KYC Details: (attach Self attested copies of following KYCs) **
a) Bank Account No .& IFS code
O4T6JO063D28
AADHAR Number (12 Digit)
c) Permanent Account Number (PAN),If available
UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowiedge
2) I authorize EPFO to use my Aadhar for verification /e KYC purpose for service delivery
3) Kindly transfer the funds and service detaiis, if applicable if applicable, from the previous PF 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
4 In case of changes In above details the same Will be intimate to employer at the earliest
Date:
Place Signature of Member
DECLARATION BY PRESENT EMPLOYER
A) The member MrMs./Mrs ..has joined on ..and has been allotted PF Number.
B) In case person was earlier not a member of EPF Schenme ,1952 and EPS,1995
(Post aliotment of UAN)The UAN Alotted 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 upioaded but not approved
t 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 PF account nurnber /UAN 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
talsutteEcate and transfer request
has been generated on portai.
As the DSC of establishment are not registered With EPFO the nember has been.informe fo fle phical çla (Fommi3) for transfer
of funds from his previous establishrnent. Dt.
Date T7:2
Signature of ploer 1gsealf Establishmen:
