Composite Declaration Form -11

(To be retained bythe employer for future reference)

EMPLOYEES’ PROVIDENT FUND ORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
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 Nameofthemember
Father'sName
2 Spouse'sName
3 Dateof Birth:(DDIMMIYYYY)
4 Gender:(Male/Female/Transgender)
5 Marital Status:(Married/Unmarried/Widow/Widower/Divorcee)
(a) EmailID -
6 (b) MobileNo. -
Presentemploymentdetails:
7 Dateof joining inthecurrentestablishment(DD/MM/YYYY)
KYCDetails:(attachself-attestedcopiesoffollowingKYCs)
a) BankAccountNo.:
b) IFSCodeofthebranch:
8
c) AADHARNumber
d) PermanentAccountNumber(PAN), if available

9 WhetherearlieramemberofEmployees'ProvidentFundScheme,1952 Yes/No
10 WhetherearlieramemberofEmployees'PensionScheme,1995 Yes/No
Previous employment details: [if Yes to 9 AND/OR 10 above) - Un-exempted
Dateof joining Dateofexit Scheme NonContrib
Universal PPONumber
Establishment PFAccount (DD/MM/ (DD/MM/ Certificate
Account utoryPeriod
Name&Address Number No. (if issued)
Number YYYY) YYYY) (NCP)Days
(ifissued

11

Previous employment details: [if Yes to 9 AND/OR 10 above) -For Exempted Trusts
Dateof SchemeC
Member Dateofexit NonContribu
joining ertificate
Name&AddressoftheTrust UAN EPSA/c (DD/MM/ toryPeriod(N
(DD/MM/ No.
Number YYYY) CP)Days
YYYY) (ifissued
12

a) International Worker: Yes/No

b) lfyes,statecountryoforigin(India/Nameofothercountry)
13
c) PassportNo.
d) Validityofpassport[(DD/MM/YYYY)to(DD/MM/YYYY)]

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.•

4) In case of changes in above details, the same will be intimated to employer at the earliest.

Date:
Place: Signature of Member
 DECLARATION BY PRESENT
EMPLOYER

A. The member Mr./Ms./Mrs................................................................................has joined on

..................................... and has beenallotted PF No. ....................................................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/e-sign.

C. In case the person was earlier 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 been approved with E-sign/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

•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.
 Employees Provident Fund Scheme
FORM – 2
(Paragraph 33 & 61(1) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employees’
Pension Scheme, 1995)
Nomination and Declaration Form For Unexempted/
Exempted Establishment
Declaration and Nomination Form under the Employees’ Provident Funds & Employees’ Pension scheme

1.Name (in block letters):______________________________________________________________________

2.Father's / Husband's Name:__________________________________________________________________
3.Date of Birth (DD/MMM/YYYY):_______________________________________________________________
4.Sex:_____________________________________________________________________________________
5.Marital Status:_____________________________________________________________________________
6.Account No:_______________________________________________________________________________
7.Address: Permanent: ________________________________________________________________________
Address: Temporary:________________________________________________________________________
8.(A) Date of Joining in E.P.F Scheme,1952_________________________________________________________
(B) Date of Joining in E.P.F Scheme,1971_______________________________________________________
(C) Date of Joining in E.P.F Scheme,1995_________________________________________________________

PART-A EPF
I hereby nominate the Person(s)/Cancel the Nomination made by me previously & Nominate the Person(s), mentioned
below to receive the amount standing to my Credit in the Employees’ Provident Fund, in the event of my Death.

Total amount or
If the Nominee is a minor, name &
Nominee’s "Date of share of
relationship & Address of the
relationship Birth accumulation in
Name of Nominee Address guardian who may receive the
with the (dd-mmm- Provident Fund to
amount during the minority of
Member yyyy)" be paid to each
Nominee
Nominee

1 2 3 4 5 6

1*Certified that I have no Family as defined in para 2(g) of the Employees’ Provident Fund Scheme, 1952 and should
I acquire a family hereafter the above Nomination should be deemed as cancelled.
2*Certified that my Father/Mother is/are dependent upon me.

* Strike out whichever is not applicable Signature or Thumb Impression of the Subscriber

PART – B (EPS) Para 18

I hereby furnish below Particulars of the Members of my Family who would be eligible to receive Widow / Children
Pension in the event of my Death.
Name and Address of the Family Date of Birth & Age Relationship with Member
Member
Sr.
No Name Address
1 2 3 4 5

* Certified that I have no family, as defined in para 2 (vii) of Employees’ Pension Scheme, 1995 and should I acquire
a Family hereafter I shall furnish Particulars thereon in the above Form.

Dated_______________
* Strike out whichever is not applicable Signature or Thumb Impression of the Subscriber

CERTIFICATE BY EMPLOYER

Certified that the above Declaration and Nomination has been Signed/Impressed before me by
Shri/Smt./Km________________________________employed in my establishment after he/she has read the
entries/entries have been read over to him/her by me and got confirmed by him/her.

Signature of the Employer or other Authorized

Officers of the Establishment Designation

Place: Designation

Date: Name & Address of the Factory /

Establishment Rubber stamp thereof.
 PAYMENT OF GRATUITY (Central) Rules.
FORM ‘F’
[ SEE SUB-RULE (1) of Rule 6 ]
NOMINATION
To,
[ I Give here name or description of the establishment with full address ]

…………………………………………………...…………………………………………………...

…………………………………………………...…………………………………………………...

1. I, Shri/Shrimati……………………………………………………………………………….
[Name in the here]

Whose particulars are given in the statement below.I hereby nominate the person(s)
mentioned below to receive the gratuity payable after my death as also the gratuity standing
to my credit in the event of my death before the amount has become payable or having
become Payable has not been paid and direct that the said amount of gratuity shall be paid
in proportion indicated against the name(s) of the nominee(s)

2. I hereby certify the person (s) mentioned is/are a member (s) of my family within the meaning
of clause (h) of Section (2) of the payment of Gratuity Act. 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the
said Act.

4. (a)My Father/Mother/Parents is/are not dependent on me.

(b) My husband’s/father/mother/parents is/are not dependent on my husband.
5. I have excluded My Husband from my family by a notice dated the …………………. to the
controlling authority in terms of the provision to clause (h) of section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

NOMINEE’S

Name in full with full Relationship with Age of Proportion by which the
address of nominee(s) the employee nominee gratuity will be shared
(1) (2) (3) (4)
 STATEMENT
1. Name of the employee in full……………………………………………………………………..
2. Sex…………………………………………………………………………………………………..
3. Religion……………………………………………………………………………………………..
4. Whether unmarried/married/widow/widower……………………………………………………
5. Department Branch/Section where employed………………………………………………….
6. Post held with Ticket No. Serial No. if any………………………………………………………
7. Date of appointment……………………………………………………………………………….
8. Permanent address………………………………………………………………………………..
Village………………………………Thana……………………Sub Division……………………
Post
Office………………………….District…………………..State…………………………….
Place-
Signature/Thumb Impression
Date……………. of the employee

Declaration by witnesses
Nomination signed/Thumb impressed before me
Name in full and full address of witnesses Signature of witnesses
1.______________________________________ 1._______________________
________________________________________
2.______________________________________ 2.______________________
______________________________________
Place:……………………
Date………………………

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this
establishment.

Employer’s reference No, if any

Signature of the employer/Officer authorized Designation

Name address of the establishment

Date……………….. or rubber stamp there of
________________________________

Acknowledgment by the employee

Received the duplicate of the nomination in Form ‘F’ Filled by me and duly certified by the
employer.

Date……………………
Note: Strike out words/paragraph not applicable Signature of the employee
 Payment of Wages (Nomination) Rules, 2009
FORM – I
Nomination and Declaration Form
(See Rule 3)

1. Name of Person making : ____________________________________________________________

nomination (in block letters)
2. Father’s / Husband’s name : ____________________________________________________________

3. Date of Birth : ____________________________________________________________

4. Sex : ____________________________________________________________

5. Marital Status : ____________________________________________________________

6. Address :
Present: ____________________________________________________________

____________________________________________________________

Permanent ____________________________________________________________
_
___________________________________________________________

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s)
mentioned below to receive any amount (unpaid wages or any other legal dues) due to me from the
employer, in the event of my death.

Name of Address Nominee’s Date of Total amount of If the nominee is a minor, na

Nominee/ relationship Birth share of and address of the guardia
nominees with the accumulations in who may receive the amou
member credit to be paid during the minority of the
to each nominee nominee
1 2 3 4 5 6

1. Certified that I have no family and should I acquire a family hereafter, the above nomination shall be
deemed as cancelled.
2. *Certified that my father/mother is/are dependent on me.
3. *Strike out whichever is not applicable.

Signature or thumb impression

of the employed person

CERTIFIED BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri./Smt./Kum employed in my
establishment after he/she has read the entry/entries have been read over to him/her by me and got
confirmed by him/her.

Place: Signature of the employer or other

authorised
Date: Officer of the establishment
and Designation

Name and Address of the Factory/

Establishment and rubber stamp thereof
 EMPLOYEES’ STATE INSURANCE CORPORATION FORM-1

To be filled in by the employee after reading instructions overleaf. Two

Postcard Size photographs are to be attached with this form. This form is free
of cost.

(A) INSURED PERSON’S PARTICULARS (B) EMPLOYER’S PARTICULARS

1. Insurance No.

2. Name
(in blockletters)
3. Father’s/Husband’s
Name
4.Date of Birth D M Y 5.Marital M/U/W
Status
6. Sex M/F

7. Present Address 8. Permanent Address

___

Pin Code …………………………… Pin Code ……………………………

E-mail address E-mail address

Branch Office Dispensary

9. Employer’s Code
No.
10. Date of Day Month Year
Appointment
11. Name & Address of the Employer

12. In case of any previous employment please fill up the

details as under:-
a) Previous Ins.No.

b) Emplr’s Code No.

C) Name & address of the Employer

E-mail address

(C) Details of Nominee u/s 71 of ESI Act 1948/Rule 56(2) of ESI (Central) Rules, 1950 for
payment of cash benefit in the event of death

Name Relationship Address

I hereby declare that the particulars given by me are correct to the best of my knowledge and
belief. I undertake to intimate the Corporation any changes in the membership of my family
within 15 days of such change.

Counter signature by the employer

Signature/T.I.of IP
Signature with Seal

(D) FAMILY PARTICULARS OF INSURED PERSON

Sl. Name Date of Birth/ Age Relationship with Whether If’No’, state place of
No. as on date of the Employee residing with Residence
filling form Him/her?
Yes No Town State
1.
2.
3.
4.
5.
6.

ESI Corporation (Valid for 3 months from the

date of appointment) Temporary Identity Card
Name
Ins. No Date of
Appointment
Branch Office Dispensary Space for Photograph

Employers Code
No. & Address

Validity:

Dated: Signature/T.I. of I.P Signature

of B.M. with Seal