Form No.

11 (New)- Declaration Form

(To be retained by the Employer for future reference)
Employees’ Provident Fund Organization
Employees’ Provident Funds 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/or EPS, 1995 is
applicable)
1 Name of the member Hemraj Saanu Sinha

Father’s Name (✓) Saanu Sinha

2
(Please tick whichever is applicable)
3 Date of Birth: ( DD/MM/YYYY ) 29/06/1995
4 Gender: ( Male/Female/Transgender ) Male
5 Marital status: (Married/Unmarried/Widower/Divorcee) Married

(a) Email ID: [email protected]

6
(b) Mobile No: 7208545966
7 Whether earlier a member of Employees’ Provident Fund Scheme, 1952 Yes
8 Whether earlier a member of Employees’ Pension Scheme, 1995 yes
Previous employment details: [if Yes to 7 AND/OR 8 above]
101314575448
a) Universal Account Number:
PY/KRP/19214/1091625
b) Previous PF Account Number:
09/08/2024
9 c) Date of exit from previous employment: (DD/MM/YYYY)
d) Scheme Certificate No. (if issued)
e) Pension Payment Order (PPO) No. (if issued)
21/08/2021
f) Date of Joining with Previous employment: (DD/MM/YYYY)
a) International Worker :
b) If Yes, state country of origin (India/Name of other country)
10
c) Passport No.
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
KYC Details: (attach self attested copies of following KYCs)
195901512370 & ICIC0001218
a) Bank Account No. & IFS Code
11 955931745494
b) AADHAR Number
FBRPS2683N
c) Permanent Account Number (PAN), if available
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/Ekyc 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
P.F. 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: 27/08/2024 Hemraj Sinha

Place: Pune Signature of Member
DECLARATION BY PRESENT EMPLOYER
A. The member Mr./Ms./Ms 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 EPS, 1995::
 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: Signature of Employer with Seal of
Establishment