DECLARATION

I,___________________________, S/o or D/o- , aged about years, by

faith –
, by occupation – , and, residing at-
________________________________________________ , do hereby solemnly affirm and declare
as follows –

1. That, I am a permanent resident of above-mentioned address.

2. That, I have been engaged with Genius Consultants Limited since_______Date

of Appointment________________.

3. That, my UAN number is ________UAN No__________________.

4. That, my PF amount for every month was deposited to Genius Employees

Provident Fund after my engagement with Genius Consultants Limited.

5. That, I have lodged a claim/advance claim for my deposited fund against my

above mentioned UAN number as on
________Date of lodging
claim________________.

6. That, I have made the claim without any misrepresentation or coercion by

any third party and same have been lodged by myself for my_____reason for
withdrawal______.

7. That, my bank account being number

AC No. of branch
Name , being IFSC code No. IFSC code of bank name
bank is registered as salary account with Genius Consultants Limited, I am
not claiming my claimed amount in my registered salary account as the
same was not in operation / blocked.
8. That, I have submitted my S/B bank account details mentioned below in
the PF portal for withdrawing my claim/advance claim against my
mentioned UAN number which is not my salary account.
Account Details:
Bank Name:
Branch Name:
Account Holder Name:
Account Number:
IFSC code:

9. That, I don’t have any objection if the claimed amount of Rs.

was transferred in the above-mentioned account details.

10. That, in future I will not be liable to claim any fraudulent transfer against
the raised claim of Rs. .

11. That, As per PAN card bearing number PAN no. my

name has been mentioned as name as per PAN and my
date of birth is mentioned as on DOB as per PAN and as per
AADHAR card bearing number AADHAR No. my name
has been mentioned as name as per AADHAR and my
date
of birth has been mentioned as on DOB as per
AADHAR , I hereby declare that name as per PAN
and name as per AADHAR are both same and
identical person and both are no one but myself and my actual date of birth
is .

12. That, as per Bank account bearing number bank A/C

no. of branch name branch of bank Name
my name has been mentioned as name as per bank
account _ and as per my AADHAR card bearing number
 /PAN card bearing number my name has
been mentioned as , I do hereby declare that
both the persons are same and identical person, no one but myself.

13. That, Genius Consultants Limited and Genius Employees Provident Fund
shall not be held liable for any fraudulent transfer against raised claim of Rs.
.

That the statements made above are true to the best of my knowledge and
belief and I am swearing this declaration without any coercion or
misrepresentation.

Signature of Deponent