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New Form No 11 - Declaration Form

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aman.negi
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596 views3 pages

New Form No 11 - Declaration Form

Uploaded by

aman.negi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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New Form No 11 – Declaration Form

(To be retained by the employer for future reference)

EMPLOYEES’ PROVIDENT FUND ORGANISATION


Employees’ Provident Fund Scheme, 1952 (Paragraph 34 & 57) &
Employees’ Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which
EPF Scheme, 1952 and EPS, 1995 is applicable)
1 Name of the Member Aman Negi
2 Fathers’ Name☐ Rakesh Singh Negi
Spouse’s Name☐
(Please tick whichever is applicable)
3 Date of Birth (DD/MM/YYYY) 04/11/2004
4 Gender (Male/Female/Transgender) Male
5 Marital Status Married
(Married/Unmarried/Widow/
Widower/Divorcee)
6 (a) Email ID [email protected]
(b) Mobile No 9310079099
7 Whether earlier a member of
EPF Scheme, 1952 ☐Yes ☐No
8 Whether earlier a member of ☐Yes ☐No
EPS Scheme, 1995
9 Previous employment details: Hindustan Wellness
[If Yes to 7 and/or 8 above] Building No 107, 1st Floor Near LIC Office,
Sector 44, Gurugram, Haryana 122001
a) Universal Account Number: 101915734306
b) Previous PF Account Number: N/A
c) Date of exit previous employment: 20/05/24
(DD/MM/YYYY)
d) Scheme Certificate No (if issued) NO
e) Pension Payment Order (PPO) No NO
(if issued)
10 a) International Worker: NO
b) If yes, state country of region
(India/Name of country)
c) Passport No:
d) Validity of Passport
[DD/MM/YYYY]
11 KYC Details:
(Attach self-attested copies of
following KYCs)
a) Bank Account Number & 7847519658 & KKBK0005289
IFSC Code
b) AADHAR Number 548768829541

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c) Permanent Account Number (PAN) CXFPN1837C

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhar for verification/authentication/KYC
purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous
PF account as declared above to the present PF Account.
(The transfer would be possible only if the identified KYC detail approved by
previous employer has been verified by present employer using his Digital
Signature Certificate)
4) In case of changes in above details, the same will be intimated to employer at
the earliest.

Date: 29th June 2023


Place: Mumbai ____Tani Lawrence______
Name & Sign

DECLARATION BY PRESENT EMPLOYER

A. The member Mr. /Ms. /Mrs. ___________________________________________


has joined on _________________________and has been allotted PF Number
____________________________.

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS,
1995:

● (Post allotment of UAN) The UAN allotted for the member is:
● Please Tick the Appropriate Option:
The KYC details of the above member in the UAN database
☐Have not been uploaded
☐Have been uploaded but not approved
☐Have been uploaded and approved with DSC

C. In case the person was earlier a member of EPF Scheme, 1952 and ESP
Scheme, 1995:

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● The above PF Account number/UAN of the member as mentioned in (A)
above has been tagged with his/her UAN/Previous Member ID as declared
by member.

● Please Tick the Appropriate Option:


☐The KYC details of the above member in the UAN database have been
approved with Digital Signature Certificate and transfer request has been
generated on portal.

☐As the DSC of establishment are not registered with EPFO, the member
has been informed to file physical claim (Form-13) for transfer of funds
from his previous establishment.

Date: 27/06/2024
Place: New Delhi Aman Negi___________
Signature of Employer with Seal

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