New Form No.

-11 — Declaration Form

(To be retained by the employer for future reference)

EMPLOYEES' PROVIDENT FUND 0 GANISATION

Employees Provident Funds. Scheme, 1952 (P ragraph 34 & 57) &
Employees' Pension Scheme, 1995 (P ragraph 24)
EPF Scheme, 1952 and /or EPS, 1995 is applicable)
I ration by a person taking up employment in any establishment on whi

Name of the member

< 41.1.111- sUL—E-T
2. Father's Name Spouse's Name ❑
(Please tick whichever is applicable) er6 C it) a— ICk 4-1"1
Date of Birth: ( DO I MM / YYYY ) o or '3
3.
Gender: e/Female/Transgender) 111
4 I Z-C-
5 Marital Status: (Married/Unrryried/Widow/Widower/Divorcee) A iA ! i Al CD

6 (a) Email ID: Lei -4-6B plat' I. S c.4

ibex

(b) - Mobile No.: 1t'l I C4 —392—e.5

-
Wheth& earlier a member of Employees' Provident Fund Scheme, 0,'9s-/ No
7
1952
Whether earlier a member of Employees' Pension Scheme, 1995 (yet"; No
8
Previous employment details: [if Yes to 7 AND/OR 8 above]
a) Universal Account Number:
6 /6 /f Ps 7 212-
b) Previous PF Account Number:
*) 0 lq gl r Ci tl e
c) Date of exit from previous employment: (DD/MM/YYYY) 113)2-0,7
d) Scheme Certificate No. (if issued)

e) Pension Payment Order (PPO) No. (if issued)

Yes / Nte7'
a) International Worker:

b) If yes, state country of origin (India/Name of other country)

10 Passport No.
c)
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
KYC Details: (attach self attested copies of following KYCs)
Bank Account No, & IFS Code
, 0,550/ 7 /rs - it3k1_00 o)2_
/43 /64/00 1
11 a)

b) AADHAR Number 7 14- /1‘. 3 I/ s-60

c) Permanent Account Number (PAN), if available hor'r& /3 7) IA
1) Certified that the particulars are true to the best of my knowledge.
I authorize EPFO to use my Aadhar for verification/authentication/eKYC purpo e for service delivery.
2)
Kindly transfer the funds and service details, if applicable, from the previous P account as declared above to the present P.F. Account.
3)
(The transfer would be possible only if the identified KYC detail approved by p evious 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 he earliest.

Date: afire of Member

Place:
DECLARATION BY PRES NT EMPLOYER
and has been allotted PF Number
The member Mr./Ms./Mrs, has joined on

B. In case the person was earlier not a member of EPF Scheme, 1952 and EP , 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
L Have not been uploaded
u. Have been uploaded but not approved
E Have been uploaded and approved with DSC
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1 95: in (A) above has been tagged with his/her LIAN/Previous
• The a5ove PF Account number/UAN of the member as mentioned
Member ID as declared by member.
• Please Tick the Appropriate Option:- ve been approved with Digital Signature Certificate and
C The KYC details of the above member in the UAN database h
transfer request has been generated on portal. member has been informed to file physical claim (Form-
c: As the DSC of establishment are not registered with EPFO, the
13) for transfer of funds from his previous establishment.

Signature of Employer with Seal of Establishment

Date:
 -;:•A`

, 14. arity of -tndia

VITSITT
Ad ress:
S/0: TPT Uallf( ), S/(: Bachan Ram, Khatauli (3),
Zratt, LiT4v4i, oReifuti, 134118 Kh auli, Panchkula, Haryana,
13 118

7486 1963 4560

1947
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INCOME TAX DEPARTMENT GOVT. OF TINDIA
r-41-41-4N-r
Permanent Account Number Card
HYOPK8507H

;Mt I Name
KAMAUEET

termeel ma I Father's Name

BACHNA RAM
16012019'
A -41 .'11
Date al Birth
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iss Ctoililmer 646: 5815 Account No.: 123.410.4000065019
ue of cheque without
funds 'Sufficient
71-LE-4 "viii
penal in the account may attract
attract Cheque Serial : 389 6 To 38985
ty under Se c.138 of NI Act Cheque leaveS : 10

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KAMALIEE.- 1 S* BAC,HAN NAGI 24119
NAI4Ak INDUSTRIAL ENT LTD 1111 11.yu HILO to share our experience and au
714AI-1R, FAct.R1,,,;;;I: tzmair 149 or have any queries
wiLL JALALPLIFt A1142.4 1.A C. ND PO DAPPA.R, at: tustarnnri areyttibi,ca.in
PAC”-i kt.,1 (PINJA1)
, 1405M
4.: Ph T1114311-11.10
a176/50Eise3., 010416e-urns
30*
Youril sincerely.
t Uht.e ` livered Fltec,e tetum to
Ctahplei.. Vv-ard nio MOO* Shsvpial., Charidegattt
n-lt•ra DrItt AS 11171 'Airifl
,;Mildha Josh
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Salary Account