JOINT DECLARATION FORM

To

The Regional PF Commissioner, BG/BNG/_________/_________

Employees PF Organisation, UAN : 101830874263
RO, Bengaluru (Central). Aadhaar No: 268140621143

Sub: Request for correction in the details of the EPF Member Account.
Sir,
I,_____________________________________________,
BALIVADA MANIKANTHA SAI an employee/ex-employee of the
establishment M/s._______________________________________
DHANI LOANS AND SERVICES LIMITED wish to inform that the following
information is/are not correctly mentioned in the PF records and hence request you to correct the
same as furnished hereunder. The print out of the UAN/PF Member ID search screenshot from
Establishment Login is enclosed for reference.

PARTICULARS AS PER PF RECORDS TO BE CORRECTED AS

Name BALIVADA MANIKANTA SAI BALIVADA MANIKANTHA SAI
Father Name
Spouse Name
PF/EPS ACCOUNT NO.
UAN
Date of birth (DD/MM/YYYY)
Date of Joining
(DD/MM/YYYY)
Date of Leaving
(DD/MM/YYYY)
Gender
Aadhaar
PAN
# Fill the columns only where changes are required.
I am enclosing herewith self-attested copy of ID Proof (PAN Card/Election ID Card/School Certificate
/Birth Certificate/Pass Port/Driving License/Aadhaar Card/ESI Card/Medical Certificate from District
Civil Surgeon authenticated by the competent court/Wage register at the time of joining/Employer
office record, etc.) which is approved in KYC for your ready reference. The documents are enclosed
as per the Annexure A.

ar details/Aadhaar based authentication for the purpose

of establishing my identity and seeding it with

All the documents (Xerox) enclosed are signed by me and attested by the employer.
Yours faithfully,
BALIVADA MANIKANTHA SAI
NAME AND SIGNATURE OF THE APPLICANT/MEMBER
Mobile No. : 8143229020
Certified that the above information is correct and request as made by the member/applicant may
please be accepted and necessary changes in your records may be made. We regret for the
inconvenience caused, if any, in this regard.

Encl: As above Employer

Seal and Signature
ANNEXURE - A

LIST OF DOCUMENTS TO BE SUBMITTED FOR CHANGE IN DATE OF BIRTH

A. Birth Certificate issued by the Registrar of Births and Deaths.

B. Any school/education related certificate.
C. PassPort
D. Any other reliable document issued by a government department
E. In the absence of proof of date of birth as above, Medical certificate issued by District Civil surgeon after
examining the member medically and support with an affidavit on oath by the member duly authenticated
by a Competent court.

LIST OF DOCUMENTS NAME (MINOR CHANGE)

A. PAN Card
B. Driving Licence
C. Election ID
D. Aadhaar

LIST OF DOCUMENTS TO BE SUBMITTED FOR COMPLETE CHANGE IN

A. Original records of the establishment such as wage register, increment Orders, Pay slips,
Appointment Order, ESIC return for the month of joining, salary credit proof for joining month
B. Advertisement published in the leading Newspaper for said changes (only if member has
changed his/her name in official records)
C. Affidavit
D. Employer separately certifying the genuineness of the request
E. Form-11 copy which was submitted by the member at the time of joining.

LIST OF DOCUMENTS TO BE SUBMITTED FOR CHANGE IN DATE OF JOINING

A. Form No. 5 issued by the employer with due attestation

B. Details of ECR paid from the date of joining of the member
C. Wage register for the month of joining
D. Employer certifying the genuineness of the request
E. Form-11 copy which was submitted by the member at the time of joining.

LIST OF DOCUMENTS TO BE SUBMITTED FOR CHANGE IN DATE OF LEAVING

A. Form No.10 issued by the employer with due attestation

B. Details of ECR paid till date of leaving
C. Wage register for the month of leaving
D. Employer certifying the genuineness of the request
E. Form-11 copy which was submitted by the member at the time of joining.