NewFormNo.

-11–DeclarationForm
(Toberetainedbytheemployerforfuturereference)
EMPLOYEES’PROVIDENTFUNDORGANISATION
Employees’ Provident fund Scheme, 1952 (Paragraph 34 & 57)
&Employees’PensionScheme,1995(Paragraph24)
(Declarationbypersontakingup employmentinanyestablishmentonwhichEPFScheme,1952and/orEPS,1995isapplicable)
1 Name of the Member Ambadipudi Sesha Sai Deepika
Father Name/Spose Name
Ambadipudi Dakshina Murthy
3 DateofBirth: (DD/MM /YYYY) 25/09/1999
4 Gender:(Male/Female/Transgender) Female
5 MaritalStatus:(Married/Unmarried/Widow/Widower/Divorcee Unmarried
a. EmailID: Deepikaambadipudi2023@gmail.com
6
b. MobileNo: 9381642252
WhetherearlieramemberofEmployees’ProvidentFund Scheme,
7 NO
1952 (Write YES if you have PF/UAN Number)
8 WhetherearlieramemberofEmployees’PensionScheme,1995 NO
(Write YES if you have PF/UAN Number)
Previousemploymentdetails:[ifyesto7AND/OR8above]
a) UniversalAccountNumber
b) PreviousAccountNumber
c) DateofexitfrompreviousEmployment:(DD/MM/YYYY)
d) SchemeCertificateNo.(ifissued)
e) Pension PaymentOrder(PPO)No...(ifissued)
a) InternationalWorker: No
b) Ifyes,statecountryoforigin(India/Nameofothercountry)
10
c) PassportNo.
d) Validityofpassport[(DD/MM/YYYY)to(DD/MM/YYYY)]
96 KYCDetails:(attachself-attestedcopiesoffollowingKYCs)
a) BankAccountNo.&IFSCCode 40285788950 SBIN0020715
b) AADHARNumber 859091819147
c) PermanentAccountNumber(PAN)ifavailable LEBPS5780P
UNDERTAKING
1) Certifiedthattheparticularsaretruetothebestofmyknowledge.
2) IauthorizeEPFOtousemyAadharforverification/authentication/KYCpurposeforservicedelivery.
3) Kindlytransferthefundsandservicedetails,ifapplicable,fromthepreviousPFaccountasdeclaredabovetothepresentP.F.Account.
(The transfer would be possible only if the identified KYC detail approved by previous employer has been verified by present employer using
hisDigitalSignatureCertificate)
4) Incaseofchangesinabovedetails,thesamewillbeintimatedtoemployer attheearliest.

Date: Guntur Deepika Ambadipudi

Place: 19-11-2023 Signature of Member

DECLARATIONBYPRESENTEMPLOYER
A. ThememberMr./Ms./Mrs.……………………………………….hasjoinedon………………………………………andhasbeenallottedPFNumber....................................
B. Incasethepersonwasearliernota memberofEPFScheme,1952 andEPS,1995:
• (PostallotmentofUAN)TheUANallottedforthememberis…………………………………………………................
• PleaseTicktheAppropriateOption:
TheKYCdetailsof theabovemember
intheUANdatabaseHavenotbeenuploaded
HavebeenuploadedbutnotapprovedHavebe
enuploadedandapprovedwithDSC
C. IncasethepersonwasearlieramemberofEPFScheme, 1952 andEPS,1995:
• TheabovePFAccountnumber/UANofthememberasmentionedin(A)abovehasbeentaggedwithhis/herUAN/
PreviousMemberIDasdeclaredbymember.
• PleaseTicktheAppropriateOption:
The KYC details of the above member in the UAN database have been approved with Digital Signature
Certificateandtransferrequesthasbeengeneratedonportal.
As the DSC of establishment are not registered with EPFO, the member has been informed to file physical claim (Form-
13)fortransferoffundsfromhispreviousEstablishment.

Date: SignatureofEmployerwithSealofEstablishment