Composite Declaration Form -11
(To be retained by the employer for future reference)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees’ Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees’ Pension Scheme, 1995 (Paragraph 24)
wor epfindia go.
(Declaration by a person taking op employment in any establishment on which EPF Scheme, 1952 and for
'S, 1995 is applicable)
1. [ Name of Member = Srinivas. Duddukunta
2. | Fathers Name Spouses Name] Diaddukunta Ramirshna Reddy
(Please Tick whiche¥ets applicable)
3. | Date of birt: (DDIMMIYYYY) 07-04-1990
4. | Gender: (MaleFemaleTranagender) Male
5. | Movtal Stas: (Maried/Unmaried/Widow/WidewenDivorcey | Married
6, | (a) Email ID:
[email protected]
(b) Mobile No: 7989021743
7. | Present employment details
Date of joining inthe current establishment (DD/IMMIYYYY) 7-11-2028
8, | KYC Daas: (tach setftested copies of following KYCS)
4) Bank Account No. 0100398652000
b) IFS Code ofthe branch HDEC0000549
©) AADHAAR Number 542928290850
4) Pexmanent Account Number (PAN), avaiable BIEPR9AASG
9. | Whether earlier a member of Employees Provident Fund Scheme,1952] Yes
10.] whether eater a member of Employees Pension Scheme, 1995 | Yes
rn Previous employment details: (if Yes fo 9 ANDIOR 10 above I - Un-exempted
- Dawsof | Dateot | Scheme Won Con
Estabishment | UAN | PP Account | jginingiade | Exitdemm | Cerifeate | PRON — | period cP)
Name & Address | Number | Number | mmyyyyy | -yyyy) | notitissued | i859 — | Daye
NIT DATA roosesaaar | aPiiyboce | 05-08-2023 [2700.20 | wa
BUSINESS ” 1335000007 :
SOLUTIONS 4835
PRIVAT
uMIrED
n Previous employment details: (if Yes to 9 AND/OR 10 above) For Exempted Frusts
Name & Adress of the uAN | Member EPS | Dateof Date of scheme] Non Cont.
Tht Number] Account | doiningtad-mm | Exitastmm | Cerificate | Period
Number “y99) “w9y) | aoGviswed) | eC) Days
15: | a) taternational Worker No
») IF yes, stale country of origin (India/Name of other country) India _
€) Passport No.
) Validity of passport [(DD/MM/Y YY) to (DD/MM/YYYY)] UNDERTAKING
1, Certified thatthe particulars are true to the best of my knowldge.
| authorize EPFO to use my Aadhaar for verfication/authentication/eK YC purpose for service delivery.
‘Account as I am an Aaadhaar verified employee in my previous PF Account
4. In case of changes in above details, the same will be intimated to employer at the earliest
Date: 07-12-2023
Place:
DECLARATION BY PRESENT EMPLOYER
‘A. The member Mr/Ms./Mrs, has joined 09 rnsenonnm and has been alloted PF number
and UAN a
BB In case the person was earlier not a member of EPF scheme, 1952 and EPS, 1995
Please click the Appropiate Option:
The KYC details of the above member in the UAN database
CG) Have not been uploaded
D)_ Have been uploaded but not approved
Have been uploaded and approved with DSC/e-sign
©. Incase the person was earlier a member of EPP scheme, 1952 and EPS, 1995:
Please click the Appropiate Option:
‘Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present P-F,
(Srinivas Duddukuntay
Signature of Member
‘The KYC details of the above member in the UAN database have been approved with E-sign/Digital Signature Certificate
and transfer request has been generated on portal
C1 The previous Account of the member is not Aadhar verified and hence physical transfer form shall be initiated.
Date: 07-12-2023 Signature of Employer with seal of establishment
* Auto transfer of previous PF account would be possible in respect of Aadhaar verified employees only. Other employees are
sequested to file physical claim (Form-13) for transfer of account from the previous establishment,
