Joint Declaration Form

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Date:

To

The Regional P F Commissioner


, .•.

Sub; Joint declaration by the member and the employer

Dear-Sir.

i
t , am! was an employee i ex employee .of

furnishing below herewith correct deans \v:th

aforesaid establishment

j Particulars Correct Particulars Wrong Particulars


I
I Name
i
I
I
I

I Father! Husband Name

I, PF !EPS Account No. I


I
~--------------------------~--------------------------~------------------~------
! Date of Birth (DD/MMiYYYY) i
~----------------------- I j
1Date of joining (DD/MM{yYYY) i
----------------------------b---------------------------~I----------------------------~
I
I/ Date of leaving (DD/MMlYYYY) I j
( ,
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I am also enclosing herewith ~ttestedt?py of ID proof (~~ - PAN ca~\dl Voters' identity Card!
Passport! Driving Licensel Aadhar Card) for your ready reference. .,,',
Therefore, you are requested to make necessary changes in your records (if required) under intimation to me
Arrearly action in this regard will be highly appreciated

Yours Faithfully

Name & Signature of Applicant

Name of Authorized Signatory

Signature VVith Establishment Seal

~, Encl. As Above

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