Form No.

11 (New)
Declaration Form
(To be retai ned by t he Employer for future reference)

Employees' Provident Fund Organization

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

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

,, NAME
1
<:'.J:~t~ \,+l~\E\N~f H IR H~f I 111 11 111111
i \u
2) DATE OF BIRTH

I~ I~ I:I~ I;I~ I~ b: I
4) RELATIONSHIP IN RESPECT OF (3) ABOVE ~ - -F-AT_H_E_R_--+-_ _
H_us_B_AN_D_ ~

(PLEASE T ICK) . \--

MALE FEMALE T RANSGENDER

5) GENDER

(PLEASE TICK) \.--

6) MOBILE N UMBER
(IF ANY)

7) EMAIL ID (IF ANY)

8)
(PLEASE TICK) YE~ NO
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES' PENSION SCHEME, 1995?
( PLEASE T ICK) ----:Y:-:-:E::--:S:---'.":"~-:----,l r - - - N - 0 - - ~ ,
rj

IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT (10,11&12):
Page 1 of 3
 OYMENT DETAILS
.,A. PR EV IO US EMPL EVIOUS PF MEMBER
ID:
MBER (U AN ) OR PR
ILS OF TH E UNIVERSAL ACCOUNT NU
lQ) THE DETA

UAN I I I
OR
ID OFFICE CODE ESTABLISHMENT ID I EXTENSION I ACCOUNT NUMBER
MBER REGION CODE
PR EV IO US PF ME
I I

D D M M
11) DATE OF EXIT FOR PREVIOUS
MEMBER ID (D D/ MM /YY YY ) r I r 1
_
MBER:_ _ _ _
YMENT, THEN SCHEME CERTIFICATE NU _ _
PREVIOUS EMPLO NUMBER:_ _ _
_
IFICATE I SSUED FOR YMENT, THEN PPO
12 ) (A ) IF SCHEME CERT O) ISSUED FOR PREVIOUS EMPLO
MENT ORDE R (PP
(B) IF PENSION PAY

8 . OTHER DETAILS
No
YES
RKER
13) INTERNATIONAL WO
(PLEASE TIC K)
13 (C ) :
13 (A ), 13 (B ) &
R THE DETAILS IN
(1 3) AB OV E IS YES, THEN ENTE
IF THE REPLY TO Tic k)
ORIGIN (Pl ea se
13 (A ) COUNTRY OF (IF YES, PLEASE
OTHER THAN INDIA
INDIA
ION NAME OF THE COUNTRY)
MENT

MBER
13 (8) PASSPORT NU

13 (C ) PASSPORTVA
UD FROM
I I
D D
IM IM I
y
Iy I Iy I
y

I I I I Iy I I I
To
I I
D D
I I I
M M
Iy Iy I
I I I I I I I I TECHNICAL/
POST DOCTOR
SEN IOR GRADUATE PROFESSIONAL
NON- MATRIC GRADUATE
ILUTERATE SECONDARY
14) EDUCATIONAL MATRIC
QUAUFICATION ~ \..------'
(PLEASE TICK)

DIVORCEE
UNMARRIED WIDOW/ WI DOWER
MARRIED
15) MARITAL STATUS
(PLEASE TICK) v-----
TEGORY
IF YES, T ICK THE CA
/ No /
/ YES HEARING
16) SPECIALLY ABLED LOCOMOTIVE
VISUAL
(PLEASE TICK)

Page 2 of 3
r -
17) KYC DETAILS I
KYC DOCUMENT T YPE
BANK ACCOUNT-1 * NAME AS ON KYC DOCUMENT
NUMBER
REMARKS IF ANY
N PR/ A ADHAAR
~' 1 ~\~ ,~L t:,( \_ CtU~5.~ ~~M\\~
PERMANENT ACCOUNT l+-b-:\.L C'\ '\...'-,~":LI •\
NUMBER (PAN )

PASSPORT

DRIVING LICENCE EXPIRY DATF

ELECTION CARD t el Y 0AH

RATION CARD

ESlC CARD

* Man dato ry Fiel d

(NOT E : BANK ACCOUNT NUM
BER (ALONG WITH IFSC COD
ARE HOWEVER ADVISED TO PROVIDE E) IS MANDATO RY. YOU
ALL KYC DOCUMENTS AVAILABLE WITH
I AVAIL BETTER SERVICES. SELF - YOU IN ADDffiON TO MANDATORY
ATTESTED PHOTOCOPIES OF THE KYCS TO
DOCUMENTS MUST BE ATTACHED
WITH THIS FORM.
C. UND ERTA KING :

A. I CERTIFY THAT ALL THE INFORMATION GIVE

N ABOVE IS TRUE TO THE BEST
B. I N CASE , EARLIER A MEMBER OF MY KNOWLEDGE AND BELIEF.
OF EPF SCHEME, 1952 AND /OR
(1) I HAVE ENSURED THE CORRECTN EPS , 1995,
ESS OF MY UAN / PREVIOUS PF
(11) THIS MAY ALSO BE TREATED MEMBER ID.
AS MY REQUEST FOR TRANSFER
THE PREVIOUS ACCOUNT AS DECL OF FUNDS AND SERV ICE DETAILS IF
ARED ABOVE TO THE PRESENT P APPt lCABLE FROM
ONLY IF THE IDENTIFIED KYC .F . ACCOUNT. (THE TRANSFER WOU
DETAILS APPROVED BY PREVIOUS LD BE POSSIBLE
EMPLOYER USING HIS DIGI TAL EMPLOYER HAS BEEN VERIFIED
SIGNATURE CERTIFICATE) . BY PRESENT
(I\\ ) I AM AWARE THAT I CAN
SUBMIT MY NOM I NATION FORM
THROUGH UAN BASED MEMBER
PORTAL

DAT E:
PLAC E:
· SI GNATURE OF MEMBER
DECLARATION BY PRESENT EMP
A. THE MEMBER Mr./ 1'45 -./~ .~'t. LOYER
rR.. '-.._ ~~ ... ... HAS JOINED ON .......
................ AND HAS BEEN ALLOTTED
PF MEMBER ID
B. IN CASE THE PERSON WAS EARUER
NOT A MEMBER OF EPF SCHEME, 1952
• (POS T ALLOTMENT OF UAN ) T AND EPS, 1995 :
HE UAN ALLOTTED FOR THE MEMBER
• IS .................. ........... .
PLEASE TICK THE APPROPRIATE
OPTION :
T HE KYC DETAILS OF THE ABOVE
MEMBER IN THE UAN DATABASE
O HAVE NOT BEEN UPLOADED
D HAVE BEEN UPLOADED BUT NOT APPR
OVED
O HAVE BEEN UPLOADED AND APPROVED
WITH DSC
C. IN CASE THE PERSON WAS EARUER
A MEMBER OF EPF SCHEME, 1952 AND
• T HE ABOVE MEMBER ID OF THE MEMB EPS, 1995:
ER AS MENTIONED IN (A) ABOVE
HAS BEEN TAGGED WITH HIS/HER
MEMBER 1D AS DECLARED BY MEMB UAN/PREVIOUS
ER.
• PLEASE TICK THE APPROPRIATE
OPTION : -
□ T HE KYC DETAILS OF THE ABOV
E MEMBER IN THE UAN DATABASE
SI GNATURE CERTIFICATE AND TRAN HAVE BEEN APPROVED WITH DIGI
SFER REQUEST HAS BEEN GENERATE TAL
□ AS THE DSC OF ESTABUSHMENT D ON PORTAL.
ARE NOT REGISTERED WITH EPFO
PHYSI CAL CLAIM (fOR M-13 ) FOR TRAN , THE MEMBER HAS BEEN INFORMED
SFER OF FUNDS FROM HIS PREVIOUS TO FILE
ESTABUSHMENT.

DATE: SIGNATURE OF EMPLOYER WITH

SEAL OF ESTABLI SHMENT
Page 3 of 3

J
r

!.nstructions fo_r filling up Declaration Form

a.
Form to be fille d in the language of th e form.
b.
Each box, wherever provided, should contain on ly
one character (alphabet /n umber
/punct uation sign) leaving a blank box after each word.
c. The item-wise lnstructlons t o fill up the form are as follow:
1.
Pl ease t ick t he Title (Mr/Ms/Mrs) an d write full name in the form
in Ite m No l. It is
reiterated th at each box h Id · . .
s o~ contain only one cha racter leaving a nlank box aft er each

wor d . It may plea se ?e noted that the Title (Mr/Ms/Mrs) should not be entered again in

t he boxes provided to write full name.

2. Please provi de Date of Birth in the form (DD/ MM/YYYY) in Item No 2.

3. Pl ease p rovide Father's/ Husband' s Name in full in the form in Item No 3. It may pl ease

be noted th at the Title {Mr/Sh .) should not be entere d agai n in the boxes provided to

write full name.

4. Please tick t h e relevant bo x in item no 4 ba sed on Item no 3. Tell lhe relationsh ip i.e.

Fath er or Husband .

5. Please Tick t he relevant Box in Item No 5 .

6. Pl eas e provi de your mo bile number on which form al com municat ion can be establish ed

and necessary information can be provided through S.M.S to the member in It em No 6.

7. Please provide e-mai l id on whic h formal commun ication can be est ablished and

necessary inform ation can be provid ed through e-mails t o t he member in Item No 7.

8. Pl ease tick 'YES' if you have previous membership of the En'ip loyees' Provident Fund

Sch eme, 1952 otherw ise 'NO' in It em No 8, w hich is a mandatory field.

9. Please t ick 'YES' if you have previous membership of t he Em pfoyees' Pensi on Sch eme,

1995 otherwise ' NO' in Item No 9, which is a mandatory field .

J[ you have ticked 'YES' in an y or both of(B} & (9) above, please folJQ.W, points 10, 11, & 12
to fill up the previous efr}ployment details at Item Numbers 1,0,11 &12, otherwise follow
13 onwards. This is very important and should be entered With 1Jtm9st care as a number
of services including tagging of various member Ws with UAN and it5: portab-ijity nre
dependent on these details.
10. Pl ease fill Universal Account Nu mber (UAN) Or Prev ious employment P.F. m ember ID in

Item No (10).

• UAN is 12 digit number wh ich has been allotted by EPFO and provid ed t o t he EPF

m em ber through em ploy er. To check whether you have bee n allott ed UAN against
 your Pf member ID, please go to the UAN Member
e-sewa on EPFO website
www.epfindia.gov.in and click on Know your UAN status.
• Previous employment P.F. member ID is to be furnished in the boxes as:
\ REG\ON CODE \ OFFICE CODE ESTABLISHMENT ID EXTENSION AccouNTNUMern

F-or instance, the numbe.rMH/BAN/'12345/123 has to entered as:

\ MH
1BAN l 12345
1
000 r123
and the number MH/BAN/12345/A/123 has to ent€red as:

\ MH l BAN ] 12345 IODA 1 123

11. Please fill Date of Exit [i .e. Date on which member has cea sed to work in the previous
establishment) for the previous employment in Item No . 11.

12. Please provide the details of Scheme Certificate in Item No . 12 (A) and r ·e nsion Payment

Order in Item No. 12 (B), if the same have been issued to the m~mber for the previous

membership .

13 . Please t ick the relevant box in Item No. 13. If you are international wbrker then fill the

boxes 13(A), 13(6) & 13(C) i.e. please provide country of origin in 13(A}. Passport Number
in 13(B) and validity period of Passport in 13(C).
14. Please tick the relevant Box for educational qual ification in lten'i No. 14.
15 . Please provide m arital Status by ticking the relevant Box in Item No. 15 .
16. Please tick the relevant box for h andicap status in Item No. 16. Ir response to this item is
YES, please tick the relevant category in the adjacent box.
17. Please . provide 'Know Your Customer (KYC)' detail s of all the tiV<iilable documents
mentioned in this column as fa r as possible. Bank account Number with I.F.S.C. code is
mandatory. Fill the name as on KYC with KYC Number and also tl'\e l'~mi:irks in Item No 17 .
Remarks col umn is to fill up t h e re levant detail s i.e. I.F.S.C. cods in case of Bank accou nt

Number, 'Valid up to' date in case of Passport, date of exp iry int.as~ of drivin g lice nse.
ft ;5 very important to note that KYC details are required to prcV[de better services to th e

members and hence details of maximum number of documents shotitd be provided in

the Item No. 17.

d. Please put your signature in the space provided with date and pla ce . Pl ease submit th e fill ed
up form to the present employer.

e. The present emp loyer is required to t ake necessa ry action as explained in detail on EPFO

We bsite und e r UAN services and fill up the necessary details with his signature , des1
. .
gnat1on
and seal in th e space provided .