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Form 11

This document is a Declaration Form for employees joining establishments under the Employees’ Provident Fund Organization, detailing personal information such as name, date of birth, gender, marital status, and contact details. It includes sections for previous employment and KYC details, emphasizing the need for accurate information for fund transfers and service delivery. The member certifies the truthfulness of the information provided and authorizes the use of their Aadhar for verification purposes.

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amitesh kumar
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12 views

Form 11

This document is a Declaration Form for employees joining establishments under the Employees’ Provident Fund Organization, detailing personal information such as name, date of birth, gender, marital status, and contact details. It includes sections for previous employment and KYC details, emphasizing the need for accurate information for fund transfers and service delivery. The member certifies the truthfulness of the information provided and authorizes the use of their Aadhar for verification purposes.

Uploaded by

amitesh kumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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,

1 Name of the member Amitesh Kumar


Father’s Name ( ) Spouse’s Name ( ) DHARMBIR KUNWAR
2 (Please tick whichever is applicable)
3 Date of Birth: (DD/MM/YYYY) 31/12/1985
4 Gender: (Male/Female/Transgender) Male
5 Marital Status: (Married/Unmarried/Widower/Divorcee) Married

(a)Email ID: [email protected]


6 (b)Mobile No: 9903753465
(c)Qualification: Bachelor of Engineering Mechanical Engineering
7 Whether earlier a member of Employees’ Provident Fund Scheme, No
1952
8 Whether earlier a member of Employees’ Pension Scheme, 1995 No
Previous employment details: [if Yes to 7 AND/OR 8 above]
a) Universal Account Number:
b) Previous PF Account Number:
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)
f) Date of Joining with Previous employment: (DD/MM/YYYY)
h) Whether Earlier PF withdrawn No
No
a) International Worker: (Only, if holding other than Indian PP)
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)] to

KYC Details: (attach self-attested copies of following KYCs)


Document Number Name as per Document
a)Bank Account No.I FSC Code & Name as per Bank
11 020153562513 AMITESH KUMAR
IFSCcode: SBIN0005376
b) AADHAR Number & Name as per Aadhar 764251512702 AMITESH KUMAR
BJCPK2148D AMITESH KUMAR
c)Permanent Account Number (PAN), if available & Name as per
PAN
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:18/11/2024 Signature of Member


Place:Pune

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