Form No.

11 (New)
Declaration Form
(To be retained by the Employer for future reference)

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 FUND SCHEME,
1952 AND/ OR EMPLOYEES PENSION SCHEME, 1995 IS APPLICABLE .
(PLEASE GO THROUGH THE INSTRUCTIONS)

1) NAME (TITLE)
MR. MS. MRS.
(PLEASE TICK)

2) DATE OF BIRTH D D M M Y Y Y Y

3) FATHER S/
HUSBAND S NAME MR

4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HUSBAND

(PLEASE TICK)

5) GENDER MALE FEMALE TRANSGENDER

(PLEASE TICK)

6) MOBILE
NUMBER (IF
ANY)

7) EMAIL ID (IF ANY)

8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PROVIDENT FUND SCHEME, 1952?

(PLEASE TICK) YES NO
9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES PENSION SCHEME, 1995?
(PLEASE TICK) YES NO
I F RESPONSE TO ANY OR BOTH OF ( 8) & ( 9 ) ABOVE IS YES , THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT
Page 1 of 3
DETAILS AT ( 10 ,11 & 12 ):

Page 2 of 3
 A. PREVIOUS EMPLOYMENT DETAILS
10) THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:

UAN
OR
PREVIOUS PF MEMBER ID
REGION CODE OFFICE CODE ESTABLISHMENT ID EXTENSION ACCOUNT NUMBER

11) DATE OF EXIT FOR PREVIOUS D D M M Y Y Y Y

MEMBER ID (DD/MM/YYYY)

(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

INTERNATIONAL WORKER (PLEASE TICK) YES NO

I F 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, PLEASE

MENTION NAME OF THE COUNTRY)

13(B) PASSPORT NUMBER _

13(C) PASSPORT VALID FROM D D M M Y Y Y Y

To D D M M Y Y Y Y

NON- SENIOR POST TECHNICAL/

14) EDUCATIONAL QUALIFICATION
ILLITERATE MATRIC GRADUATE DOCTOR
MATRIC SECONDARY GRADUATE PROFESSIONAL
(PLEASE TICK)

MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE

15) MARITAL STATUS (PLEASE TICK)

16) SPECIALLY ABLED YES NO IF YES, TICK THE CATEGORY

(PLEASE TICK)
LOCOMOTIVE VISUAL HEARING

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17) KYC DETAILS KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* IFSC CODE*
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT EXPIRY DATE
DRIVING LICENCE EXPIRY DATE
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

C. UNDERTAKING :
A. I CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF .
B. I N CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/ OR EPS, 1995 ,
( I ) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID .
( I I ) 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. (T HE TRANSFER WOULD BE
POSSIBLE ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY
PRESENT EMPLOYER USING HIS D IGITAL SIGNATURE CERTIFICATE ).
(I I I ) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL .

DATE:
PLACE: SIGNATURE OF MEMBER

A. THE MEMBER
DECLARATION BY PRESENT
HAS JOINED ON AND HAS BEEN ALLOTTED PF MEMBER ID

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 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 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

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 Instructions for filling up Declaration Form
a. Form to be filled in the language of the form.
b. Each box, wherever provided, should contain only one character (alphabet /number
/punctuation sign) leaving a blank box after each word.
C. The item-wise instructions to fill up the form are as follow:
1. Please tick the Title (Mr/Ms/Mr5) and write full name in the form in Item No 1. It is
reiterated that each box should contain only one character leaving a biank box after each
word. It may please be noted th at the Title (Mr/Ms/M rs) shou!é not !›e entered again in
the boxes provided to write full name.
2. Plea5e provide Date of Birth in the form (DD/MM/YYYY) in Item No 2.
3. Please provide Father’s / Husband’s Name in full in the form in hem No 3. It may please
be noted that the Title (Mr/Sh.) should not be entered again i! the boxes provided to
write fu(I name.
4. Please tick the relevant box in item no 4 based on Item no 3. Tell the relationship i.e.
Father or Husband.
5. Please Tick the relevant Box in Item No S.
6. Please provide your mobile number on which formal communication can be established
and necessary information can be provided through S.M.S to the r<nifer in Item No 6.
7. Please provide e-mail id on which formal communication can be established and
necessary information can be provided through e-mails to the a L* T\ h er in Item No 7.
8. Please tick ‘YES’ if you have previous membership of the Employees’ Provident Fund
Scheme, 1952 otherwise ‘NO’ in Item No 8, which is a m andatord lieIN
9. Please tick ‘YES’ if you have previous membership of the Employees’ Pension Scheme,
1995 otherwise ‘NO’ in Item No 9, which is a mandatory field.
I[ you have ticked ’YES’ in any or both of (8) & (9| above, please fo//ow points 10, 11, &
12 to fi!! p the previous employment details at Item NumberS 10!, ! 1 &12, otherwise
follow 13 onwards. This is very important and should be entered s•.its uimost care as a
number o( services including taqginq o( various member Iâs with LAN und its‘ portability
are dependent on these details.
10 Please fill Universal Account Number (UAN) Or Previous employment P.F. member ID in
Item No (10).
• UAN is 12 digit number which has been allotted by EPFO and provided to the EPF
member through employer. To check whether you have been allotted UAN against
 your PF member ID, please go to the UAN Member e-sewa on EPFO website
www.epfindia.Nov.in and click on Know your UAN status.
• Previous employment P.F. member ID is to be furnished in the boxes as:

REGION CODE OFFICE CODE ESTABLISHMENT I D EXTENSION ACr U ›v— i.'1^4ER

!
For instance, tne number \1fg/’dAN/1' 2S45/123 has to entered as:

MH BAN 12345 OOO 12?

anci the numt er MH/BAN/12345/A/123 has to entered as:
MH BAN 12345 OOA 123

11. Please fill Date of Exit (i.e. Date on which member has ceased Ie 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 Pension Payment
Order in Item No. 12 (B), if the same have been issued to the member for the previous
membership.
13. Please tick the relevant box in Item No. 13. If you are internation.II worker then fill the
boxes 13(A), 13(8) & 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 qualification in Item No. 1.4.
15. Please provide marital Status by ticking the relevant Box in Item No. ?! 5.
16. Please tick the relevant box far handicap status in Item No. 16. If response to this item is
YES, please tick the relevant category in the adjacent box.
17 Please provide ‘Know Your Customer (KYC)’ details of all th.e available documents
mentioned in this column as far as p ossibl e. Ba nk acco unt Number with 1. F.S.C. code is

mandatory. Fill the name as on KYC with KYC Number and a(so L' !r. remarks in Item No
17 Remarks colum n is to fill up the relevant details i.e. I.F.S.C. code ir r.a.se of Bank
account Number, ‘Valid up to’ date in case of Passport, date of expiry in c‹J° of driving
license.
It is very important to note that KYC details are required to pr Idea bed er services to the
members and hence details of maximum number of documents s.la uld be provided in
the Item No. 17.
d. Please put your signature in the space provided with date and place. Please submit the
filled up form to the present employer.
e. The present employer is required to take necessary action as explained in detail on EPFO
website under UAN services and fill up the necessary details with is signature,
designation and seal in the space provided.