Form No.

11 (New)
Declaration Form
(To be retained by the Employer for future reference)

Employees' Provident Fund\JOrganization

THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57)
&
THE EMPLOYEES' PENSION SCHEME, 1995 (PARAGRAPH-24)

FUND SCHEME,
DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES' PROVIDENT
1952 AND [QR EMPLOYEES' PENSION $CHEME. 1995 IS APPLICABLE, '\
(PLEASE GO THROUGH THE INSTRUCTIONS)

2) DATE OF BIRTH

4) RaATIONSHIP u, RESPECT<>' (3) """"' I

(PL.fASE T1ac)

5) GENDER
(PL.fASE TIClC)
~
>
,~,--,
6) MOBIL£ NUMBER
(IF ANY) / -:J- / 0 //J_l9L l4
~
lg 1~1i 1-:J-- l l? I
7) EMAIL ID (IF ANY}

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES' PROVIDENT fUND SCHEME, 1952?

{PlEAsE TICK) YES 7 NO
9) WHETHER EARUER A MEMBER OF THE EMPLOYEES' PENSION SCHEME,1995?
{PlEAsETICK) .--- -Y-ES- /------,,----.- ---N-0-- ~

IF RESPONSE 10 ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORil,Y FIU UP THE PRMOUS EMPLOYMENT DETAILS
AT (10,11&12):
Page 1 of 3
 pa :::]
A. PRMOUS EMPLOYMENT DETAILS
S PF MEMBER ID:
10) THE DETAILS OF THE UNMRSAL ACCOUNT NUMBER (UAN) OR PREVIOU

UAN
OR
I I I O 10 16 l':1-- 1~ IQ 1£ I ~ I S-- 1~ IC>
ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER
PRMOUS PF MEMBER ID REGION CODE OFFICE CODE

SCHEME CERTIACATE NUMBER:. _ _ __

12) (A) IF SCHEME CERTIACATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN
THEN PPO NUMBER:, _ _ _ __
(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT,

E.:B._ 0THER DETAILS

=----~--------~ YES No
13) INTERNATIONAL WORKER
(PLEAsE n0<)
IN 13(A)1 13(B) & 13(C):
IFTHE REPLY TO (13)ABOVE IS YES, THEN ENTER THE DETAILS
13(A) CouNTRY OF ORIGIN (Please lick)
INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)

13(B) PASSPORT NUMBER

13(C) PASSPORT VAUD FROM 0 0

l l l ~ l"ly lyl y l y l

To 0 0
l l l" l "ly lyl y l y l

SENIOR Posr TEa-tNICAl./

14) EDUCATIONAL
NON·
MATRIC GRADUATE OOCTOR PROFESSIONAL
IWTERATE MATRIC SECONDARY GRADUATE
QUAUACATION ►
(Pl.EASE TIC<) ✓

WIDOW/ WIDOWER DIVORCEE

15) MARITAL STATUS
(Pl.EASE TIC<)

IF YES, ncK THE CATEGORY

16)5PECIALLY ABLED
LOCOMOTIVE VISUAL HEARING
(Pl.EASE TIC<)

Page 2 of 3
 NUMBER REMARKS IF ANY
KYC DocuMENT TYPE NAME AS ON KYC DocuMENT
17) KYC DETAILS Tfr§Y1/J000of3l
BANK ACCOUNT-1 * 0 <;'.s ~ 9 1CJ oo oo l'~~ NA 7£ ft f-1. PAftf,
NPR/AADHMR -=1-ll ~~ 33 6 ~ (' si~
PERMANENT ACCOUNT
NUMBER {PAN) C3> t3 fl PN 8' 6 ==1-3 D
EXPJPY 0 /IF
PASSPORT
EXPIRY DATE
DRMNG LICENCE
;-
ELECTION CAAD ' ·•,._
RATION CARD
'
,r l.'"\, 'j~
.
ESICCARD I
ER (ALONG WITH IFSC CODE) IS MANDATORY, YOU
* Mandatory Field (&rn : BANK ACCOUNT NUMBAVAILABLE WITH YOU IN ADDffiON TO MANDATORY KYCS TO
ENTS
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUM THIS FORM.
TED PHOTO COPIES OF THE DOCUMENTS MUST BE ATTACHEDWITH
AVAIL BETTER SERVICES. SELF-ATTES

--- =- --= -= --- --- --- ---'-

:
. .,/
,..,...,~.--- ·• -- -- -~ -- -- -- --
a • 51
)

j C. UNDERTAKING;
F,
IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIE
A. I CERlIFY THAT ALL THE INFORMATION GIVEN ABOVE
ER OF EPF SCHEM E, 1952 AND/OR EPS, 1995,
B. IN CASE, EARLI£R A MEMB US PF MEMBER ID, /
(I) I HAVE ENSURED THE CORRECTNESS OF MY UAN
/ PRMO ,
FOR TRANS FER
~

OF FUNDS AND SERVICE DETAI LS IF APPLICABLE FROM

(D) THIS MAY ALSO BE TREATED AS MY~REQUEST D BE POSSIBLE
THE PRESENT P.f, ACCOUNT, (THE TRANSFER WOUL
..
THE PRMOUS ACCOUNT AS DECLARED ABO\'E,-,TO .;
YER HAS BEEN VERIF IED BY PRESENT
VED BY PREVI OUS EMPLO
ONLY IF THE mENTIFIED ICYC DETAILS APPRO
FICATE).
EMPLOYER USING HIS DIGITAL SIGNATURE CERTI L.
I CANSUBMIT MY NOMIN ATION ,FORM THROUGH UAN BASED MEMBER PORTA
(DI) I AM AWARE THAT
wi1'::-
'~·
\ ~ f/'
lo /oJ.tf u,2. ,3 ~~
~ SIGNATURE oF MEMBER
PLACE: /3_ ll!:L~d' Lot. ~ '
ENT EMPLOYER
,_ - - - - - - - DECLARATIOf tBY PRES
A ?E JOINED ON ......... .............. AND HAS
.MEMBER.Mr./Ms./Mrs. _-··...:::·\~. : ......... ...... HAS
BEEN ALLOTTED PF MEMBER ID

EPF ScHEME, 1952 AND EPS, 1995:

8. IN CASE THE PERSON WAS EARLIER NOT AMEMBER OF
(POST ALLOTMENT Of UAN) THE UAN ALLOTTED FOR THE MEMBER IS ......... .....................
•
• PLEASE 'TIC!(THE APPROPRIATE Omo N:
DATABASE
THE KYC DETAILS OF THE AW:M. MEMBER IN THE UAN
0 HAVE NOT BEEN UPLOADED
□ HAVE BEEN UPlOADEO BUT NOT APPROVED
□ HAVE BEEN UPLOADED AND APPROVED WITH DSC
1995:
IN CASE THE PERSO N WAS EARLIER~ MEMBER OF EPF ScHEME, 1952 AND EPS,
C.
MENTIO NED IN (A) AOOVE HAS BEEN TAGGED WITH HIS/HER UAN/PREVIOUS
• THE AW:M. MEMBER ID OF THE MEMBER AS
MEMBER ID AS DEa.ARED BY MEMBER.
• PLEASE 'TICK THE APPROPRIATE Omo N:- L
UAN DATABASE HAVE BEEN APPROVED WITH DIGITA
0 THE KYC DETAILS OF THE APO./E MEMBER IN THE
BEEN GENERATED ON PORTAL.
SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS
NT ARE NOT REGISTERED WITH EPFO, THE MEMBER HAS BEEN INFORMED TO FILE
□ As THE DSC OF ESTABUSHME
FROM HIS PREVIOUS ESTABUSHMENT.
PHYSICAL QAIM (FoRM-13) FOR TRANSFER OF FUNDS

LISHMENT
SIGNATURE OF EMPLOYER WITH SEAL OF ESTAB
DATE:
Page 3 of3
,
 FORM - 2 ( Revised)

NOMINATION AND DECLARATION FORM

FOR EXEMPTED/ UNEXEMPTED ESTABLISHMENTS
Declaration and NominatJon Fonn Under the Employee's Provident Funds & Employees' Pension Scheme
(Paragraph 33 & 61 (1) of the Employees' Provident Fund Scheme, 1952 & Paragraph 18 of the Employees's Pension Scheme, 1995)

1 Name ( In Block Letters) I\JA2..ef M PAS¼-\A

2 Fa¥er•s / Husband's Name Ml\ ~001... AHMtD
3 Date of Birth lb 0~ l ~ 9C
4 Sex {vi~\...~
5 Marital Status MA-P-il.\ ~O
6 Account Number I I
7 Address Permanent 0 ~d1,1 Mw'vt

Temporary
.s e,, P~"' ~ ~ \.-\C4. CM. (s I \(o/'I.L-z._1

8 Date of Joining
EPF
EPS

PART- A (EPF)

I here by nominate the person(s) / cancel the nomination made by me previously and person(s) mentioned below to
receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death.

Name &t Address of the Nominee's relationship Date of Total amount of share of if the nominee is minor name &
Nominee/ Nominees with the member Birth accumalation in provident address &: relationship of the
fund to be paid to each nominee guardian who may recive the amount
1 2 3 4 5
lb
FAtl Y)
fNAM S Pov Sc -.......
0
I oO °I~
--J .)
..c

Certified that I have no family as defined in para 2 (g) of the Employee's Provident Fund Scheme 1952 and should I
1 acquire a family hereafter the above nomination should be deemed as cancelled
2 Certified that my father / mother is / are depended upon me.
3 Unmarried members in the absence of dependent parents may nominate any other per~ receive the shares

Note: A Fresh nomination shall be made by the member on ~~

his/ her marriage and any nomination made before such
marriage shall be deemed to be invalid Signature .h~pre,sion of th• Subscribe<
 PART- B (EPS)

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

S.No
1 Ar.JAM '1,//0 / 6
2

Certified that I have no family as defined in para 2 (vii) of the Employee's Pension Scheme 1995 and should I acquire a
family hereafter the above nomination should be deemed as cancelled

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16(2) (g) (I) &
(ii) in the event of my death with out leaving any eligible family member for receiving pension.

Name & Address of the Nominee Date of Birth Relationshi with the member

f+NAM f8R\YA
--:p. J-.'f / , o , €> ~ 0tersJ , 4 ~OW/\
~

6C>MjM~

Date : I O / 0 Lr / '2-0 ~1 X
Signature/ Thumb impression of the subscriber

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before 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:
Date :
Signature of the mrpluytr

Name & Address of the Establishment

l