New Form No.1 ~ Declaration Form (ote retained by the employer fr fture reference) EMPLOYEES’ PROVIDENT FUND ORGANISATION Employes’ Provitert Fund Scheme, 1952 (Paragraph 348 57) & Employee’ Panton Scheme, 1865 (Paragraph 24) (Dectaration by a person taking up employment in any establishment on which EPF Scheme, 1952 and Jor EPS, 1005 is appiicabl) +, | Name of the member —— ~~ Fates Wome Eo] Spa's None (lose te utesoversoptcate) Date of Bt: (97MM YY) Gace ke Farol Tanagende |) Marital Status (Mar“ied/Unmarried/Widow/Widower/Divorce: (a) Email 1D; a ‘Whether ener @ member af Employees Pension Saieme, 1585 Yon ho Previous employment details: [i Yes to 7 AND/OR 8 above] | 2) Unversal Account Number Tb) Brenous > Raxount Number ‘€) Date of exit from previous employment: (DD/MM/YYYY) __ @)_ Scheme Certificate No” ((Fissued) — [e)__ Pension Payment Order (PPO) No. (issued) ‘@) International Worker: Yes/No Bf yes, site country of origin (india/Name of other courty) 2) Passport Vo. <)_Vildity of passport [(OD/MM/NYYY) to (DD/MMIVYYY)] KYC Details: (attach self attested copies of following KYCS) — 11 [ay Bank Account, BFS Cade - 10 int Number (PAN), i evelebie UNDERTAKING 1), Cartes that the particulars ae true to the best of my knowledge, 2) authorize EPFO to use my Aacha for verfcation/authentication/eKYC purpose for service delivery 3), Kindly transfer the funds ans service deta, applicable, from the previous PF account as decared above to the present PF, Account. (The transte: would be possible only if the identfed KYC detal approved by previous employer has been verified by present employer ‘sing his Dita Signature Certificate) 1). Incase of changes in above details the same wil be intimates to employer atthe earliest. Date: Pace: Signature of Member (DECLARATION BY PRESENT EMPLOYER A. The member Mr/Ms./Mrs has joined on and hasbeen allotted PF Number 8. Incase the person was earer not a member of EPF Scheine, 1952 and EPS, 1995: (Post allotment of UAN) The UAN allotted for the member is + Please Tick the Appropriate Option: ‘The KYC cetalls ofthe above memiber in the JAN database. Have not been uploaded Have been uploaded but not approved Have been uploaded and approved with DSC Incase the person was earler a member of EPF Scheme, 1952 and EPS, 1995: ‘77 The azove PF Account number/UAN of the meme” as mentioned in (A) above has been tagged with his/her UANYPrevious Memter ID as deiared by member. ‘+ Please Tick the Appropriate Option: © THEKYC details cf the above member in the UAN database have been approved with Diatal Signature Cericate and transfer request has been generated or posta. As the DSC of establishment are not registered with EPFO, the member has been informed to fe physica! claim (Form 123) for transfer of funds from his prevcus estat shment. Date: Signature of Employer with Seal of Establishment