SAW FORM si New Form No.11- Declaration Form (oe retuned by the employer for fatre reference) EMPLOYEES PROVIDENT FUND ORGANIZATION Emp Code: Employees provident funds scheme, 1952 (paragraph 34 & 57) & : Employees pension scheme 1995 (paragraph 24) Comeany (Declaration bya person taking up employment in any establishment on which EPF Scheme, 1952 end /oF EPS1993 is applicable) T__ [Name of the member JOHN QoE | Father's Name (_) Spouse's Name () (Please Tick Whichever Is Applicable) AARON Ove 3_[ Date of Binh (ODMMIYYYY) 2) Lo Zo0o | Gender (male Female Transgender) MLE '3_| Marital Status (married /Unmarried fwidowavorss) ONMpReT ED © | @EmailD: To. bt (e)Mobile No: 4444 9499 49 7e_| Whether earliera member of Employees "provident Fund Scheme 1957 Yes. Noo S| Whether ealiera member of Employees ‘Pension Scheme 1995 Yes 0. Noo Tf response to any or both of (7) & @) above is yes. MANDATORY FILL UP THE (COLUMNS) a) Universal Account Number(UAN) Toe a ») Previous PFweNo [AP HYD | EST.CODE [EXIN | PFNO.] I ° | 9) Date of exit ftom previous employment (DDIMMIVYY) I I Scheme Cerificat No (Issued) al ©) Pension Paymient Order (PPOWNo (FTasued) Intemational Worker Yeo Noo 19 [-®)_1¥es, State Country OF Origin (india Name of Oiher County) ©) Passport No. Validity Of Passpor(DDAIMIVYY) to DIMIMVVY) KYC Details (attach Sef attested copies of following RVG) == 2) Bank Account No & IFS code 1 [)_AADHAR Number (12 Digit 4455 6666 TTT ©)_Permanent Account Number (PAN) available AGBCDEN2Z3H UNDERTAKING 1) Certified that the Particulars are true to the best of my Knowledge 2) Lauthorize EPFO to use my Aadhar for verification / © KYC purpose for service delivery 3) Kindly wansfer the funds and service deals, if applicable if applicable, from the previous PF account as declared above to the 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 4) Incase of changes In above details the same Will be intimate to employer atte earliest Ze Dat: Torq oe. Place Signature of Member -LARATION BY PRESENT EMPLOVER A). The member Me/Ms es a joined on and hasbeen alloted PF Number. B) Incase person vas eater note member of EPF Scheme ,1952 and EPS 1998 + (Post allotment of VAN ) The UAN Alloted forthe member is + Please tick the Appropriate Option: +The KYC deus ofthe ove member inthe UAN database 5 Have not ben uploaded 1 Hive been uploaded but ot approved ©. Have been uploaded and approved with DSC ©) Incas ihe person vas eater a member of EPF Scheme 1952 and EPS, 1995: * The above PF ascount umber JUAN ofthe member as mentioned in 4 above as boen tagged wth his/her UAN/peviou emer ID as declared by member ‘Please Tick the Appropriate Option 5. The KYC deus ofthe sbove member inthe UAN database have ben aproved with digital signature Cerificate and rnsfer request has ben generted on pt 2 Asthe DSC ofesublishnent ar not registered With EPFO the member hasbeen informed to fle physial lim (Form) fr transfer of finds fom his previous establishment Date ‘Signature of Employer With seal of Establishment