NEW FORM NO.
11 - Declaration Form
(To be retained by Employer for future reference)
Employees' Provident Fund
Organisation The Employees' Provident Funds
Scheme, 1952 (Paragraph - 34 & 57) and
The Employees' Family Pension Scheme, 1995 (Paragraph - 24)
DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EPF SCHEME, 1952 AND / OR EPS,1995 IS APPLICABLE
1. Name of the member
2. Father's Name Spouse's
Name (Please tick whichever is
applicable)
3. Date of Birth: (DD / MM / YYYY)
4. Gender: (Male / Female / Transgender)
5. Marital Status:
(Married/Unmarried/Widow/Widower/Divorcee)
6. (a) Email ID:
(b) Mobile No.:
7. Whether earlier a member of Employee's Provident Fund Yes / No
Scheme, 1952 8. Whether earlier a member of Employee's Yes / No
Pension Scheme, 1995
Previous Employment details (if Yes to 7 and/or 8 above)
(a) Universal Account Number :
9. / /
(b) Previous PF Account Number :
(c) Date of exit from previous employment (DD/MM/YYYY):
(d) Scheme Certificate No. (if issued):
(e) Pension Payment Order (PPO) No. (if issued):
(a) International Worker: Yes / No
10. (b) If yes, state country of origin (India / Name of other Country)
(c) Passport No.
(d) Validity of Passport (DD/MM/YYYY) to (DD/MM/YYYY) / /
KYC Details: (attach self-attested copies of following
KYCs) 11. (a) Bank Account No. & IFSC Code
(b) AADHAR Number
(c) Permanent Account Number (PAN), if available
UNDERTAKING
1) I certify that all the information given above is true to the best of my knowledge and belief.
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 th present P.F.
Account.
(The transfer would be possible only if the identified KYC details 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 Signature of
Member Place
DECLARATION BY PRESENT EMPLOYER
A. The member Mr./MS./Mrs. has joined on 01/02/2024 and has been allotted PF Member ID _____________________
B. In case, the person was earlier not a member of EPF Scheme, 1952 and/or
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
