New Form No.

-11 -Declaration Form

(To be retained by the employer for future referencej
EMPLOYEES' PROVIDENT FUND ORGANISATION
Emplyes Provident Fund Schene 1952 (Paragrach 34 &57) &
Empioyees Persion Scheme, 1985Paragraçh 24)
Deciarator by a person taking up empioyment in any estabishment on which EPF Scheme, 1952 and lor EPS, 1995 is açplicatie)
Name of the member

Father's Nanne Souse's Name

Please hoahchever is applicabie RADHAKRISHNA
Date of Bth (DO MM/YYYY)
Gender (Male Femaie Transgender) 25/05/1324
Nartal Status (Nared Unmarred Widow Widower/Divorce2) MALE
a) Ema D:
MARRIED
tharantharanD0ma-Con
Ncbie Nc q566223616
Whether earher a member of Emmployees Provident Fund Scteme, Yes /H
1952
Whether earler a member of Empioyees Pension Scheme, 1995 Yes /
Previous employment details: [if Yes to 7 ANDJOR 8 above]
aUhversal Account Number io03904Sr|62
b) Prevous F Acrount Number:
Date of et from previous empioyment (DD/MMYY TN MAS31/2-12023
O0192480000003372
d Scheme Certficate No. (f issued)
e Penson Payment Order (PPO) No. (f issued)
aIntematonal Worker

b) yes, state country cf origin (Inda Name of other counitry)

c Passport No
Not APPLicabl e
validty of passport [(DO MM YYY) to (DD vMYYYY] NO Aeflicablc
KYC Details: (attach self attested copes offolowing KYCS)
a) Bank Account No. &IFS Code 000901613457TCÍC ODD 0o 09
b) AAD-AR Number 8265 7737 8172
c) Permanent Acnount Number (PAN), f available AHHTO785D
UNDERTAKING
1 Cetfed thar the particulars are true to the best of my knowledge
Z lauthonze EPFOto use my Aadhar for verificationauthentcaionvekYC purpose for service delvery.
) Kindy transer thefunds and service detals, f applicable, frorn the prevous PF account as decared above to the present PF. AcCDunt
(The transfer wouid be possible onily if the identfied KYC detal approved by previous employer has been verfied by present employer
LSing his Dgtal Signature Cartifcate)
4 In caseaf changes nabove detals, the same wil be intimates to empioyer at the earliest
Date 05/0l |2023
Place CHENNAL Signatire of Member
DECLARATION BY PRESENT EMPLOYER
The member MrMs/Mrs has oned on and has been allotted PF Number

In case the person was earlier not a member of EPF Scheme 1952 and EPS, 1995
(Post allotment of UAN) The UAN alotted for te member is
Please Tick the Appropriate Option:
The KYC details of the above member in the JAN database
Have not been uploaded
Have been upioaded but not approved
Have been uplcaded and approved wit DSC
C In case the person was earier a member of EPF Scheme, 1952 and EPS, 1995
The aove PF Account numberUAN of the membe as menticned in (A) above has been tagged with nis/her UAW/Preious
Memter ID as deciared by member.
Please Tick the Appropriate Option:
The KYC detals of the above member in the UAN database have been approved with Digital Sgnature Certficate and
transfer request has been generated on portal
As the DSC of estabilishment are not regstered ith EPFO, the member has been informed to fle physical cdam (Form
13) for transfer of funds from his previous estab shment.

Date Signature of Employer with Seal of Establishment