www.epfindia.eov.
in
Composite Declaration Form -11
EMPLOYEES’ PROVIDENT FUND ORGANISATION
Employee’ Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees• Pension Scheme, l99S (Paragraph 24)
Name of the member
Father Name
2 Spouse’s Name
3 Date of Birth: ( DD / MM / YYYY )
4 Gender: (Male/Female/Transgender)
5 Marital Status: (Married/Unmarried/Widow/Widower/Divorcee)
(a) Email ID:
6
(b} Mobile No.:
Present employment details: (Date of Joining)
7 Date of joining in the current establishment (DD/MM/YYYY)
KYC Details: (attach self attested copies of following KYCs)
a) Bank Account No. :
8 b) IFS Code of the branch:
d) Permanent Account Number (PAN), if available
Whether earlier a member of Employees’ Provident Fund Scheme,
9 1952
10 Whether earlier a member of Employees’ Pension Scheme, 1995
Previous employment details: [if Yes to 9 And OR l0 Above] - Un-exempted
Establishment Universal PF Account Date of joining Date of Scheme PPO Number Non
Name & Address Account Number (DD/MM/ YYYY) exit Certificate (if issued) Contributory
Number (DD/MM/ No. (if Period
YYYY) issued (NCP) Days
Previous employment details: [If Yes to 9 AND/OR 10 above] — For Exempted Trusts
Name & Address of the Trust UAN Member Date of Date of exit Scheme Non
EPS A/c joining (DD/MM/ Certificate Contributory
Number (DD/MM/ YYYY) No. (if Period (NCP)
YYYY) issued Days
12
a) International Worker:
13 b) If yes, state country of origin (India/Name of other country)
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
UNDERTAKING
I) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhar for verification/authentication/e-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 PT.
Account as I am an Aadhar verified employee in my previous PF Account.*
4) In use of changes in alive details, the same will be intimated to employer at the earliest.
Signature Of Member
DECLARATION BY PRESENT EMPLOYER
A. The Member Mr/ Ms/ Mrs ......................................................................... has joined on ......................,................
Allotted PF No. .........,............................................................aml L'AN.................................................................................................
B. In case person was ‹earlier not a member of EPF Scheme, 1952 and UPS, 1995:
• Please Tick the Appropriate Option:
The KYC details of the above member in the UAN database
O Have not been uploaded
O Have been uploaded but not approved
O Have been uploaded and approved with DSC/e-sign.
C. In case the person was earlier a member of I\PF Scheme, 1952 and UPS, 1995:
Please Tick the Appropriate Option:-
O The KYC details of the above member in the UAN database have been approved with E-sign/Digital Signature
Certificate a0d transfer request has been generated on portal
O The previous Account of the member is not Aadhar verified and hence physical transfer from shall be initiated
Date: Signature of Employer with Seal of
Establishment
*Auto transfer of’ previous PF account would be possible in respect of Aadhar verified employees only. Other employee’s arc requested to
file physical claim (Fomi-13) fa transfer of account from the previous establishment.
