Form No.

11 (Revised)
(For unexempted establishments only)

THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 (Paragraph 34)

And
THE EMPLOYEES FAMILY PENSION SCHEME, 1995 (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 / D/o____________________________________
Do hereby solemnly declare that
(a)
I was employed in M/s
_______________________________________________________________________________________
(Name & Full address of the establishment)
and left service on _____________prior that, I was employed in ____________________________
_____________________________________________________From ____________to _________
(e) I was member of_____________Provident Fund and also/but not of the family Pension Fund from
_______________to ______________ & my account number(s) was/were____________________.
(e)
(e)
(e)

I have/have not withdrawn the amount of my Provident Fund/Family Pension Fund.

I have/have not drawn any superannuation benefits in respect of my past service from any
employer.
I have/have never been a member of any Provident Fund and/or Family Pension Fund.

__________________________________________________
Signature of left/right hand thumb impression of the employee

Date

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

Shri _________________________________________is appointed as______________________________

(Name of the Employee)
(Designation)
in M/s _________________________________________________________________________________
(Name of the Factory/Establishment)

With effect from___________________________

(Date of appointment)
Date of admission of member of Employees Provident Fund ______/_____/____________
Account No. DL/________________________________________

Signature of Employer/Authorize officer.

(With Official Seal)