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Employee Provident Fund Declaration Form

This document is a declaration form for new employees joining an establishment that enforces the Employees' Provident Funds and Family Pension Fund Scheme. The form collects information about the employee's previous employment and membership in provident funds. The employee declares whether they were previously a member of a provident fund, if they have withdrawn or received benefits from any past funds, and provides their account numbers and pension details. The employer verifies and signs the form, providing the new employee's appointment details and assigned PF account number.

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214 views1 page

Employee Provident Fund Declaration Form

This document is a declaration form for new employees joining an establishment that enforces the Employees' Provident Funds and Family Pension Fund Scheme. The form collects information about the employee's previous employment and membership in provident funds. The employee declares whether they were previously a member of a provident fund, if they have withdrawn or received benefits from any past funds, and provides their account numbers and pension details. The employer verifies and signs the form, providing the new employee's appointment details and assigned PF account number.

Uploaded by

kishore112ww
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FORM 11 ( Revised)

THE EMPLOYEES PROVIDENT FUNDS SCHEME,1952 (Paragraph 34)

THE EMPLOYEES FAMILY AND PENSION SCHEME, 1971 (Paragraph 19)

Declaration by a person taking up employment in an establishment in which


the Employees Provident Funds & Family Pension Fund Scheme enforce

I.......................................................................S/o/W/o/Daughterof..................................................
( NAME OF EMPLOYEE )
do hereby solemnly declare that :-

(a) I was employed in M/s.........................................................................................................


(NAME AND FULL ADDRESS OF THE ESTABLISHMENT)

and left service on ....................prior to that, I was employed in..................................


( DATE ) (NAME AND FULL ADDRESS
..........................................................................from.......................................to......................................
OF THE ESTABLISHMENT) ( DATE ) ( DATE )

(b) I was member of ........................................Provident Fund and also/but


( Name of Trust or R. P. F. C.)
not of the Pension Fund from.....................................to....................................... and my account
( DATE ) ( DATE )
number (s) was/were..............
( PF No. )
(c) I have/have not withdrawn the amount of my Provident Fund/Pension Fund.

(d) I have/have not drawn any superannuation benefits in respect of my past service from any employer.

(e) I have/have not never been a member of any Provident Fund and/or Pension Fund.

(f) I am drawing/not drawing Pension under EPS 95.

(g) I am a holder/not holder of scheme Certificate.

(h) Scheme certificate surrendered/not surrendered.

Date............................. Signature or left hand thumb


impression of the employee.

(To be filled by the employer only when the person employed had not already been a member of the
Employees Provident Fund)

Shri/Smt.....................................................................is appointed as.................................................


(NAME OF EMPLOYEE) (DESIGNATION)
in M/s.............................................................................with effect from..........................
(NAME OF THE FACTORY/ESTABLISHMENT) (DATE OF APPOINTMENT)

P.F. Account Number .

Date............................ Signature of the Employer/Manager or Other


Authorised Officer

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