FORM NO.

:1

FORM FOR COLLECTING DATA FOR MEDICLAIM FACILITY.

1. Name of the Staff Employee : Your Name

2. Name of the company : As mentioned in Offer Letter

3. Emp Code : Location:As mentioned in Offer Letter

4. Details of the family :

[Please include name of the staff member (self), wife/ husband, Father/ Mother
and maximum two numbers children. Children up to age of 25 years only to be
included. They should be unmarried and not employed.

Age
Sr. Relation with Date of
Name Years completed as
No Staff member Birth
of 01/04/2023
1 Your Name Self DD/MM/YYYY Age

2 Mother’s Name Mother DD/MM/YYYY Age

3 Father’ Name Father DD/MM/YYYY Age

4 Spouse’s Name Husband/Wife DD/MM/YYYY Age

5 Kid’s Name Son/Daughter DD/MM/YYYY Age

6 Kid’s Name Son/Daughter DD/MM/YYYY Age

5. Joining date of the employee: DD/MM/YYYY DATE OF JOINING

6. Signature of the employee: please sign here_ Date : DD/MM/YYYY

For Office Use :

Name of HRD Officer: ___________________________

Signature of HRD Officer: ____________________ Date: ______________

 FORM NO.:2 PAGE 1

FORM 'F'

[See sub-rule (1) of rule 6]

Nomination

To ……………………………………………………..…………………………..

[Give here name or description of the establishment with full address]

I. Shri/Shrimati/Kumari Your Name whose particulars are given in the statement below,
[Name in full here]
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 a/are 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)

Name in full with full Relationship with the Age of nominee Proportion by which
address of nominee employee the gratuity will be
shared

Name *Mandatory *Mandatory *Mandatory

Address
 FORM NO.:2 PAGE 2

Statement

1. Name of employee in full -

2. Sex -

3. Religion -

4. Whether unmarried/married/widow/widower -

5. Date of appointment -

6. Permanent address -

Village ……………… Thana ……………… Sub-division ………………. Post Office ………………

District ………………. State…………………

(please sign here)

Place Signature/Thumb impression
Date DD/MM/YYYY of the employee ***Your Signature

DATE OF JOINING

Acknowledgement by the employee

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

(please sign here)

Date: DD/MM/YYYY Signature of the employee***Your Signature

 FORM NO.:3 PAGE 1 (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)

1. Name (IN BLOCK LETTERS) :

Name Father’s / Husband’s Name Surname

2. Date of Birth : DD/MM/YYYY 3. Account No. Please mention Bank Account Number

4. *Sex : MALE/FEMALE: 5. Marital Status (as applicable)

6. Address Permanent / Temporary : As per Adhar card

PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below
to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee

1 2 3 4 5 6
*Mandatory *Mandatory *Mandatory *Mandatory *Mandatory

1 *Certified that I have no family as defined in para 2 (g) of the Employees 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.

(please sign here)

Strike out whichever is not applicable Signature/or thumb impression of the
subscriber ***Your Signature

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. No Name & Address of the Family Member Age Relationship with the member

(1) (2) (3) (4)

*Mandatory *Mandatory *Mandatory
 FORM NO.:3 PAGE 2
Certified that I have no family as defined in para 2 (vii) of the Employees’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.

Name and Address of Date of Birth Relationship with member

the nominee
*Mandatory *Mandatory *Mandatory

Date: DD/MM/YYYY

DATE OF JOINING
(please sign here)
Signature or thumb impression of
the subscriber ***Your Signature

CERTIFICATE BY EMPLOYER *For office use

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 authorised officer of the

establishment

Place :
Name & address of the Factory /Establishment
Date :
 FORM NO.:4
New Form : 11 - Declaration Form
(To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND ORGANISATION

Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)

1. Name of Member (as per Aadhar Card)

Father's Name Spouse's Name
2. (Please tick whichever applicable)

3. Date of Birth (dd/mm/yyyy)

4. Gender (Male / Female / Transgender)
5. Marital Status ? (Single/Married/Widow/Widower/Divorcee)

(a) eMail ID
6.
(b) Mobile No (Aadhar Registered)
Whether earlier member of the Employee's Provident Fund
7. Yes / No (as applicable)
Scheme, 1952 ?
Whether earlier member of the Employee's Pension
8. Yes / No (as applicable)
Scheme, 1995 ?
Previous Employment details ? (If Yes, 7 & 8 details above) If any
a) Universal Account Number (UAN)
b) Previous PF Account Number If any
9.
c) Date of Exit from previous Employment ? (dd/mm/yyyy) If any

d) Scheme Certificate No (If issued)

e) Pension Payment Order (PPO) (If issued)
a) International Worker Yes / No
b) If Yes, state country of origin (name of other country)
10.
c) Passport No.
d) Validity of passport (dd/mm/yyyy) to (dd/mm/yyyy)
KYC Details : (attach self attested copies of following KYC's) Must Enclose Scan copy for the following documents

a) Bank Account No. & IFSC Code

11.
b) AADHAR Number
c) Permanent Account Number (PAN), If available

After Sep 2014 earned EPS

First EPF Member First Employment EPF Are you EPF Member If Yes, EPF Amount If Yes, EPS (Pension)
(Pension) Amount Withdrawn
Enrolled Date Wages before 01/09/2014 Withdrawn? Amount Withdrawn?
12. before Join current Employer?

Yes / No Yes / No Yes / No Yes / No

UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge

2) I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
3) Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to the present PF 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
4) In case of changes in above details, the same will be intimated to employer at the earliest.

DATE OF JOINING
Date : (DD/MM/YYYY) (please sign here)
Place : (as applicable) Signature of Member ***Your Signature

DECLARATION BY PRESENT EMPLOYER *For office use

A. The member Mr./Ms./Mrs. ……………..…………………….. Has joined on ……………………….and has een alloted PF Number ……….……..

B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995: ((Post allotment of UAN) The UAN alloted or the member is)
Please Tick the Appropriate Option : The KYC details of the above member in the JAN 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 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 : Signate of Employer with Seal of Establishment

 Employee Data Collection Form FORM
Company Name : ** Company Name as mentioned in Offer Letter
NO.:5
Emp. Code : ** Gender :
Employee Name : Your Name

Department : Department as mentioned in Offer Letter

Designation : Designation as mentioned in Offer Letter

Location with State :

Father's Name :
Blood Group :
Date of Joining :
Date of Birth :

Present Add. :

Pin code:

Permanent Add. : As per adhar card

Pin code:

Personal Email ID :

Personal Contact No. :

Emergency Contact No. :

Relationship :
Please intimate if you or any of Relationship with the person Employed:
your close relative (e.g. parent,
spouse, child or sibling) is/was Name of the Government Organisation:
working in any Government
organization. Duration:

Pan Card No.: (Attachment

(your PAN card no.)
required for records)

Aadhar Card No.:

(Attachment required for (your Adhar card no.)
records)

Previous Employer UAN No.:

(if applicable)
If Any
Specially Abled
If Any
(If Any, with details)

Bank Account Details (Attachment required for records - cancelled cheque (Name, Account No. & IFSC Code))

Name of emp. in Bank : (as applicable)

Bank Name : (as applicable)

Account No. : (as applicable)

IFSC Code : (as applicable)

Declaration
□ There are no criminal proceedings, offence or prosecution going on against me or pending in any legal entities. anywhere in
India. I hereby declare that the information given above is true to the best of my knowledge.
Signature (please sign here) ***Your Signature Date : DD/MM/YYYY

DATE OF JOINING
 FORM NO.:6
JOINT DECLARATION UNDER PARA 26(6) OF THE EPF SCHEME, 1952

To,
Regional EPF Commissioner,

Sub: Application for regularising membership/Provident Fund Contributions deducted on Salaries over & above Rs.
15000/- per month or at higher rate.

Sir,

I the undersigned Shri/Smt. Your Name

bearing Account Number ---------- , employee of M/s Company Name As mentioned in Offer Letter

hereby declare that I have been contributing Provident Fund on my entire salary @ 12% with effect from DD/MM/YYYY.

I am/am not an `EXCLUDED EMPLOYEE’ within the meaning of para 2(f) of the EPF Scheme, 1952 DATE OF
I request that; JOINING
1. I may be enrolled as member of the Employees’ Provident Fund voluntarily with effect from DD/MM/YYYY .
2. I may be permitted to contribute voluntarily on my entire salary exceeding Rs. 15000/- per month w.e.f.DD/MM/YYYY

3. I may be permitted to contribute @ -----% instead of the statutory rate of 12% with effect from DD/MM/YYYY

Yours Faithfully,

(please sign here)

(Member’s signature)

*For office use

We M/s , bearing Employer’s Code No.

hereby declare that;

1. We have voluntarily enrolled Shri/Smt.

as member of the EPF Scheme, 1952, w.e.f. and his/her Account Number is .
2. We have been deducting contribution on his/her entire pay w.e.f.
3. We have been making matching contribution on pay upto Rs. 15000/- per month / on entire pay w.e.f.
.
4. We have been deducting Provident Fund contribution voluntarily @ 12% of pay and making matching contribution @
12% of pay.
5. We have paid Administrative Charges and submitted all the Returns in respect of the above
Member accordingly and will continue to do so.

We request that this case be regularised by permitting voluntary membership and contribute on entire salary @ 12% of pay
as stated above.

Yours Faithfully,