EMP ID:
www.epfindia.gov..in
Composite Declaration Form -11
(To be retained by tire employer for future reference)
EMPLOYEES' PROVIDENT FUND ORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57)
& Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking op employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995 is applicable)
1 Name of the member ABC DEF XYZ
Father's Name XYZ DEF ABC
2
Spouse's Name
3 Date of Birth: ( DD I MM I YYYY ) XX/XX/XXXX
4 Gender: (Male/Female/Transgender) MALE/FEMALE/TRANSGENDER
5 Marital Status: (Married/Unmarried/Widow/Widower/Divorcee) MARRIED/UNMARRIED/WIDOW/WIDOWER/DIVORCE
(a) Email ID:
[email protected]6 (b) Mobile No.: XXXXXXXXXX
Present employment details:
7 Date of joining in the current establishment (DD/MM/YYYY) LEAVE IT BLANK
KYC Details: (attach self attested copies of following KYCs)
a) Bank Account No. : XXXXXXXXXXX
8 b) IFS Code of the branch: ABCD00XXXXX
c) Name As Per Bank ABC DEF XYZ
a) AADHAR Number : XXXX XXXX XXX
b) Name As Per AADHAR : ABC DEF XYZ
a) Permanent Account Number (PAN), if available ABCDE0000F
b) Name As Per PAN ABC DEF XYZ
9 Whether earlier a member of Employees' Provident Fund Scheme, 1952 Yes / No
10 Whether earlier a member of Employees' Pension Scheme, 1995 Yes / No
Previous employment details: [ifYes to 9 AND/OR 10 above)-
Un-exempted
Establishment Universal PF Account Date Date of exit Scheme PPO Non
Name & Address Account Number ofjoining (DD/MM/ Certificate Number Contributory
Number (DD/MM/ YYYY) No. (if (ifissued) Period
YYYY) issued (NCP) Davs
MANPOWER/ 1012129 ABC/ Refer to Service History
11
ONTRACK in UAN Portal @
XXXXX XXXXX/ https://unifiedportal-
WITH XXXXX mem.epfindia.gov.in/mem
ADDRESS OF berinterface/
CAOMPANY For both dates.
Previous employment details: [if Yes to 9 AND/OR 10 above) -For Exempted Trusts
Name & Address of the Trust UAN Member Date of Date of exit Scheme Non
EPS A/c joining (DD/MM/ Certificate Contributory
Number (DD/MM/ YYYY) No. (if Period (NCP)
YYYY) issued Days
12
a) International Worker: Yes / No
13 b) lf yes, state country of origin (India/Name of other country)
c) Passport No.
d) Validity of passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
UNDERTAKING
I) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my Aadhar for verification/authentication/e—KYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present P.F. Account as I
am an Aadhar 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.
SIGN HERE
Date:
Place: Signature of Member
DECLARATION BY PRESENT EMPLOYER
A. The member Mr/Ms/Mrs ∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙ has joined on .....................................................and has been
allotted PF No. ∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙.and UAN∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙∙
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
• Please Tick the Appropriate Option:
The KYC details of the above member in the UAN database
Have not been uploaded
Have been uploaded but not approved
Have been uploaded and approved with DSC/e-sign.
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS, 1995:
• Please Tick the Appropriate Option:-
0 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.
D The previous Account of the member is not Aadhar verified and hence physical transfer form shall be initiated
Date: Signature of Employer with Seal of
Embellishment
•Auto transfer of previous PF account would be possible in respect of Aadhar verified employees only. Other employees are requested to
File physical claim (Fonn-13) for transfer of account from the previous establishment.
