NON EMPLOYEMENT CERTIFICATE

( SELF DECLARATION BY THE MEMBER/CLAIMANT )

I, ………………………………………………………………………S/W/ of……………………………………………………………………

Residing at…………………………………………………………………………………………………………………………………………

………………………………………………………do hereby solemnly affirm and sincerely state as hereunder.

I, ………………………………………………………………………S/W of………………………………………………………………………

Declare that I/…………………………………………… was an employee of M/s ………………………………………………..

Bearing PF A/c No. ……………………………………………., left the job on dated……………………………on covered

under the Employee`s Pension Scheme-1995/EPF Scheme-1952, prior to the date of joining the

establishment after the date of leaving service from the above establishment.

And declare that I am not receipt of any pension benefits under Employees Family pension 1971/
Employee`s Pension Scheme 1995.

That is stated above said information is true and correct to the best of my knowledge.

In case, my above declaration is found to be false, I undertake to return the pension in full with

Interest as declared by Employee`s Provident Fund Organisation and I am abiding for my action that

may be intimated by EPFO, in this regard.

Solemnly affirmed at,

On this day………………………. Signature of Member/Claimant