Declaration Form

New Form No.-11

employer for future
reference)
(To be retained by the
EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Funds Scheme,(Paragraph 34 & 57) &

1952

24)
Employees Pension Scheme, 1995 (Paragraph
Deciaration by a person taking up employment in any establishment on which EPF Scheme. 1952 and /or EPS, 1995 Is applicabi

1 Name of the member SOMBATHINT SURYA TEJA

2 Father's Name Spouse's Narne SOMBATHTNT VEJAYA KUMAR
(Please tick whichever is applicable)
-
3.
4
Date of Birth: (DDIMM/YYY)
Gende: (Male/Female/Transgender)
O6l08/1196
MALE
5MaritalStatus (Mared/Unmarried/idow/Widower/Divorcea)
UN MARRIED
6 (a)Email 1D: SuTyatja 4s1® gmalco m
b) Mobile Nc 176124l&S
7 Whether earlier a member of Employees' Provident Fund Scteme, Yes/ No
1952
Whether earlier a member of Employees' Pension Scheme, 1995 Yes/No
Previous employment details: [if Yes to 7 AND/OR 8 above]
a) Universal Acco.nt Number:

b) Previous E Account Number

c)Date of exit from previous employment: (DD/MM/YYYY)

- -
--
d) Scheme (Certficate No. (if issued)
e)Pension Fayment Order (PPO) No. (if issued)
a) Internationat Worker: Yes/ No

b ) f yes, state country of origin (India/Name of other country)

10C)PassportNo.
d)Validity o passport{(OD/MMYY) to (DD/MM/Y]
KYC Details: (attach self attested copies of folowing KYCs)

11 a) Bank Account No. & IFS Code

88lo02420876
b) AADHAR Nurnber
c)Permanent Account Number (PAN), if available
G65704415443
FBFPS 3433
UNDERTAKING
Certifiec tha: the particuars are true to the best of my knowle dge.
2 I authorize EPFCO to use my Aadhar for verification/authenticatior/eKYC purpose for service delivery
Kindly transfer the funds and service details, if applicable, frorn the previous PF account as declared above to the present P.F. Account.
(The transfer would be passible only if the identified KYC deta:l approved by previcus employer has been verified by present employer
using his Digital Signature Certificate)
4) In case of cthanges in above detail's, the same wil be intimatej to employer at the earliest.

Dete 14/o4/21 CwmayS

Place: Chennad Signature of MerMber
DECLARATION BY PRESENT EMPLOYER
A The memper Mr./Ms./Mrs. nas joined on *********.**.***
..and has been allotted PF Number
******

8. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
(Postallotment of UAN) The UAN allotted for the memberis ******************
Please Tick the Appropriate Option:
Tre 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
In case 'he person was earlier a member of EPF Scherne, 1952 and EPS, 1995:
The a ove PF AcCOunt number/UAN of the memie" as mentioned in (A) above has
been tagged with nis/her
Me'nter 1D as declared by meinber IAN,Previous
Please Tick the Appropriate Option:
he KYC getails of the above memter in he UAN database have
Deen approved with
transfer reQuest has been generated on portal. Digital Signature Certficate and
As tne DSC of establishment are not registered
wiln EPFO,
:3) for transter of funds from hiS previous estib'shrnent.
the member has been informed to file
physical claim (Fom

pate Signature of Enployer with Seal of Establishment