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Form No.11 UAN Declaration Form (8) - Copy

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Abilash Iyer
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51 views

Form No.11 UAN Declaration Form (8) - Copy

Uploaded by

Abilash Iyer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 4

Employee No.

:_ G702322
Form No.11 (New)
Declaration Form
(To be retained by the Employer for future reference)

Employees' Provident Fund Organization


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

DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES’


PROVIDENT FUNDS SCHEME, 1952 AND / OR THE EMPLOYEES' PENSION SCHEME, 1995 IS APPLICABLE
(PLEASE GO THROUGH THE INSTRUCTIONS)

1) FULL NAME: MR./MS./MRS. Abilash Raman Iyer

2) DATE OF BIRTH (DD/MM/YYYY) 20/08/1991


3) FATHER'S/ HUSBAND'S NAME: MR. Venkat Raman Iyer
RELATIONSHIP IN RESPECT OF (3) FATHER HUSBAND
4) ABOVE (Please tick)
5) GENDER (Please tick) MALE FEMALE

TRANSGENDER
6) MOBILE NUMBER 9004096029
7) EMAIL ID [email protected]
8) WHETHER EARLIER A MEMBER OF THE YES NO
EMPLOYEES' PROVIDENT FUNDS
SCHEME, 1952? (Please tick)
9) WHETHER EARLIER A MEMBER OF THE YES NO
EMPLOYEES' PENSION SCHEME, 1995?
(Please tick)

IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY
FILL UP THE PREVIOUS EMPLOYMENT DETAILS AT (10, 11 &12):

A. PREVIOUS EMPLOYMENT DETAILS


10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF
MEMBER ID:
UAN : 1 0 1 1 3 6 4 8 3 9 1 9

OR

Employee No.:____________
Page 1 of 4
PREVIOUS PF MEMBER ID:
REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER

11) DATE OF EXIT FOR PREVIOUS MEMBER ID (DD/MM/YYYY) : ____________________

12) (A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME
CERTIFICATE NUMBER : ____________________

(B) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO
NUMBER : ________________________

B. OTHER DETAILS

13) INTERNATIONAL YES NO WORKER:

(Please tick)

IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13 (C):

13(A) COUNTRY OF ORIGIN (Please tick)


INDIA OTHER THAN INDIA (IF YES, MENTION NAME
OF THE COUNTRY)

13(B) PASSPORT NUMBER : Z7138992

13(C) PASSPORT VALID FROM : 11/03/2023


TO : 10/03/2033

14) EDUCATIONAL QUALIFICATION : (Please tick)


ILLITERATE NON- MATRIC SENIOR GRADUATE POST DOCTOR TECHNICAL/
MATRIC SECONDARY GRADUATE PROFESSIONAL

15) MARITAL MARRIED UNMARRIED WIDOW/WIDOWER DIVORCEE


STATUS
(Please tick)

16) SPECIALLY ABLED


(Please tick) YES NO

Page 2 of 4
Employee No.: G702322

17) KYC DETAILS :


KYC DOCUMENT NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF
TYPE ANY
BANK ACCOUNT -1 * Abilash Raman Iyer 50100221004539 HDFC0000544
NPR/AADHAR Abilash Raman Iyer 561960276995
PERMANENT Abilash Raman Iyer ABOPI1391R
ACCOUNT NUMBER
(PAN)
PASSPORT
DRIVING LICENCE
ELECTION CARD
RATION CARD
ESIC CARD
* Mandatory Field (NOTE : BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS
MANDATORY. YOU ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE
WITH YOU IN ADDITION TO MANDATORY KYCS TO AVAIL BETTER SERVICES. SELF-ATTESTED
PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.

C. UNDERTAKING:

A) I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
B) IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND / OR EPS 1995,
I. I HAVE ENSURED THE CORRECTNESS OF MY UAN /PREVIOUS MEMBER ID.
II. THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND
SERVICE DETAILS IF APPLICABLE FROM THE PREVIOUS ACCOUNT AS
DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT.(THE TRANSFER WOULD BE
POSSIBLE ONLY IF THE IDENTIFIED KYCDETAILS APPROVED BY PREVIOUS
EMPLOYER HAS BEEN VERIFIED BY PRESENT EMPLOYER USING HIS DIGITAL
SIGNATURE CERTIFICATE.
III. I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED
MEMBER PORTAL.

DATE: 02/04/2024

PLACE: Thane SIGNATURE OF MEMBER

Page 3 of 4
DECLARATION BY PRESENT EMPLOYER

 THE MEMBER Mr./Ms./Mrs. _______________________HAS JOINED ON ___________ AND HAS


BEEN ALLOTTED PF MEMBER ID ____________________________
 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__________________
Employee No.:__G702322

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

 IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME 1952 AND EPS 1995:
 THE ABOVE MEMBER ID 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 AND TRANSFER REQUEST HAS
BEEN GENERATED ON PORTAL
 AS THE DSC OF ESTABLISHMENT ARE NOT REGISTERED WITH EPFO, THE
MEBER 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

Page 4 of 4

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