www.epfindia.gov.

in

Composite Declaration Form-11

(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 end /of EPS1995 is applicable)
 UNDERTAKING
1) Certified that the Particulars are true to the best of my Knowledge.
2) I authorize EPFO to use my Aadhar for verification / e KYC 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 as I am an Aadhar verified employee in my previous PF Account.*
4) In case of changes In above details the same Will be intimate to employer at the earliest
Date:01/10/2024

Place: Bangalore Pooja Singh

1 Name of the member Pooja

2 Father’s Name () Shambhu Singh
Spouse’s Name ()
(Please Tick Whichever Is Applicable)
3 Date of Birth (DD/MM/YYYY) 12/12/2000

4 Gender: (male / Female /Transgender) Female

5 Marital Status (married /Unmarried /widow/divorce) Unmarried
6 (a) Email ID: singhpooja62159@gmail.com
9315162159
(b) Mobile No:
7 Present Employment details: Voya Global Service Pvt Ltd
Date of joining in the current establishment (DD/MM/YYYY) DOJ – Today’s date
8 a) Bank Account No : 3347670028
b) IFS Code of the branch : KKBK0000181
c) AADHAR Number 93627885455
d) Permanent Account Number (PAN),if available JBQPK7785G
9 Whether earlier a member of Employees ‘provident Fund Scheme 1952 Yes
1 Whether earlier a member of Employees ‘Pension Scheme ,1995 Yes
0
Previous employment details [if yes to 9 AND/OR 10 above] – Un-exempted
Establishment Universal PF Date of Date of Exit Scheme PPO Non
Name & Account Account Joining (DD/MM/YY) Certificate Number(If Contributory
Address Number Number (DD/MM/YY) No.(if Issued) period(NCP)Days
1
issued)
1
Sandmartin 101865 00101 25/08/202 30/9/2024
consultants
pvt.ltd Noida 271709 92 2
sector -7 U.P
201301

1 Previous employment details: [ if Yes to 9 AND / OR 10 above] – For Exempted Trust

2 Name & UAN Member Date of Joining Date of Exit Scheme Non Contributory
Address of the EPS A/C (DD/MM/YY) (DD/MM/YY) Certificate period(NCP)Days
Trust Number No.(if
issued)

a) International Worker: No
1 b) If Yes , State Country Of Origin (India /Name of Other Country)
3 c) Passport No
d) Validity Of Passport (DD/MM/YYY) to(DD/MM/YYY)
www.epfindia.gov.in

DECLARATION BY PRESENT EMPLOYER

A) The member Mr./Ms./Mrs ………………..has joined on …………….and has been

allotted PF Number………………………………. And UAN ……………………..

B) In case person was earlier not a member of EPF Scheme ,1952 and EPS,1995
● 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/e-sign.

C) In case the person was earlier a member of EPF Scheme ,1952 and EPS, 1995:
● 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.
◻ The previous Account of the member is not Aadhar verified and hence physical transfer form shall be initiated.

Date
Signature of Employer With seal of Establishment
 * (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED

ESTABLISHMENTS
Declaration and Nomination Form under the Employees Provident Funds and Employees’ Pension
Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the
Employees’ Pension Scheme 1995)

Name (in BLOCK Letters) Pooja Date of Birth 12/12/2000

Father’s / Husband Name Shambhu Singh Account No -

Sex (Male / Female) Female Marital Status Unmarried

Address (Permanent / Rza-55 Rohtash nagar gali no.-2 mahavir enclave palam village south
Temporary) west delhi -110045

PART A (EPF)

If the Nominee
is a minor,
Total
Name &
amount of
Nominee Relationship &
Name of the share of
s relation Date of Address of the
Nominee/Nomine Address Accumulatio
with the Birth guardian who
es n in PF to be
member may receive the
paid to each
amount during
Nominee
minority of
nominee

792A Mahavir
enclave part 2 25/07/19
Geeta Devi
Street-20 New Delhi
Mother
85
100% -
-110059

1. *Certified that I have no family as defined in para 2(g) of the Employee’s Provident Fund
Scheme, 1952 and should I acquire a family hereafter the above nomination should be
deemed as cancelled.

2. *Certified that my father/mother is/are dependent upon me.

Pooja Singh

Strike out whichever is not applicable Signature/or thumb impression of the subscriber
 PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children
Pension in the event of my premature death in service.

Sr. Name of the Family Relationship with

Address of the Family Member Age
No Member the member

1 Geeta Devi 792A gali no.-20 Mahavir 39 Mother

enclave part -2 new Delhi -
110059

Certified that I have no family as defined in para 2 (vii) of the Employee’s Family Pension Scheme 1995 and
should I acquire a family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i)
& (ii) in the event of my death without leaving any eligible family member for receiving pension.

Sr. Relationship with

Name of the Nominee Address of the Nominee
No the member

Date: 1/10/2024

Pooja Singh

Signature or thumb impression of the subscriber

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by
Shri / Smt/ Miss ______________ employed in my establishment after he/she has read the entries /
the entries have been read over to him/her by me and got confirmed by him/her.

Date: Signature of the employer or other

authorized officer of the
Establishment

Name & Address of the Factory / Establishment

Place: Bangalore

Date:
 PAYMENT OF GRATUITY ACT.
Form ‘F’
[SEE SUB-RULE (1) of Rule 6]

NOMINATION

To,

VOYA Global Services Pvt. Ltd.

(Formerly Known as VFI SLK SEZ UNIT, 3rd Floor, Tower A,
Amin Properties LLP SEZ,
Sy nos. 19.20/1, 20/2, Poojanahalli,
Devanahalli, Bangalore- 562110)

1. I, Shri/Shrimati/Kumari Pooja Singh

whose particulars are given in the statement below, hereby nominate the person(s)
mentioned below to receive the gratuity payable after my death as also the gratuity
standing to my credit in the event of my death before that amount has become payable, or
having become payable has not been paid and direct that the said amount of gratuity shall
be paid in proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is/are a member(s) of my family within the
meaning of clause
(h) of Section 2 of the Payment of Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of Section 2 of the
said Act.

4 (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the to the controlling
authority in terms of the proviso to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Proportion by
Relationship
Sr. A which the
Name of the nominee Address of the nominee with the
No ge gratuity will be
member
shared

1 Geeta Devi Mother 3 100%

792A Mahavir enclave part 2 9
Street-20 New Delhi -110059

Statement
 Name Pooja
Sex Female
Religion Hindu
Whether unmarried/married/widow/widower Unmarried
Department/Branch/Section where employed Process Associate
Post held with Ticket No. or Serial No., if any -
Date of appointment 10/12024
Permanent address Rza-55 gali no. -2 Mahavir enclave part 2 New Delhi 110059

Place: Bangalore Pooja Singh

Signature/Thumb-impression of the Employee

Date: 1/10/2024

Declaration by Witnesses

Nomination signed/thumb-impressed before me

Name in full and full address of witnesses Signature of the Witness

Blank

Place:

Date:

Certificate by the Employer

Certified that the particulars of the above nomination have been verified and
recorded in this establishment

Employer's Reference No., if any _______________ Signature of the employer/Officer

authorised
Designation:

Date: Name and address of the establishment

or
rubber stamp thereof

Acknowledgement by the Employee

Received the duplicate copy of nomination in Form 'F' filed by me and duly certified
by the employer

Date : Signature of the

employee

Note.—Strike out the words/paragraphs not applicable

 Nomination Form

I, Pooja Singh Emp ID No.:a fulltime employee of Voya Global Services Private Limited (Company)do
hereby nominate (Satyam) residing at 792A Mahavir enclave street no.-20 part 2 New Delhi -110059
my Brother<<relationship with Employee>>, as my nominee to receive all my compensation dues
from the Company, other than the statutory dues, in the event of my unforeseen demise during my
tenure of employment with the Company.

_____________________________
Place: Bangalore
Date: 10/1/2024
Sign: Pooja Singh