New Form : 11 - Declaration Form
(To be retained by the employer for future reference)
EMPLOYEES' PROVIDENT
FUND ORGANISATION
Employees' Provident Fund Scheme, 1952 (Paragraph 34 & 57) and
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up Employment in any Establishment on which EPF Scheme, 1952 and for EPS, 1995 is applicable)
VIDHI HEMANT DHONE
1 Name of Member (Aadhar Name)
.
Father's Name Spouse's Name HEMANT HANSRAJ DHONE
2 (Please tick whichever applicable)
.
09/02/2000
3 Date of Birth (dd/mm/yyyy)
.
FEMALE
4 Gender (Male / Female / Transgender)
.
SINGLE
5 Marital Status ? (Single/Married/Widow/Widower/Divorcee)
.
[email protected] (a) eMail ID
6 8669039059
. (b) Mobile No (Aadhar Registered)
Whether earlier member of the Employee's Provident
7 Fund Scheme, 1952 ? No
.
Whether earlier member of the Employee's
8 Pension Scheme, 1995 ? No
.
YES
Previous Employment details ? (If Yes, 7 & 8 details 101965253957
above)
a) Universal Account Number (UAN)
THVSH0115809000006832 0
9 b) Previous PF Account Number
02/09/2023
. c) Date of Exit from previous Employment ? (dd/mm/yyyy)
d) Scheme Certificate No (If issued)
e) Pension Payment Order (PPO) (If issued)
a) International Worker No
b) If Yes, state country of origin (name of other country)
1
c) Passport No.
0.
d) Validity of passport (dd/mm/yyyy) to (dd/mm/yyyy)
KYC Details : (attach self attested copies of following KYC's) Must Enclose Scan copy for the following
documents
50100608833151
1 a) Bank Account No. & IFS Code
1. b) AADHAR Number
751334798420
FNXPD9306K
c) Permanent Account Number (PAN), If available
After Sep 2014 earned EPS
First EPF First Employment Are you EPF If Yes, EPF If Yes, EPS (Pension) Amount
Member EPF Member before Amount (Pension) Withdrawn before Join
1 Enrolled Wages 01/09/2014 Withdrawn Amount current Employer?
2. Date ? Withdrawn?
Yes / No Yes / No Yes / No Yes / No
UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge
2) I authorise EPFO to use my Aadhar for verification / authentication / eKYC purpose for service delivery
3) Kindly transfer the fund and service details, if applicable, from the previous PF account as declared above to the present PF account.
(The transfer would be possible only if the identified KYC details approved by previous employer has been verified by present employer using his Digital Signature 4) In case
of changes in above details, the same will be intimated to employer at the earliest.
Date : 3/08/2024
Place : NAGPUR Signature of Member
DECLARATION BY PRESENT
EMPLOYER
A. The member Mr./Ms./Mrs. ……………..…………………….. Has joined on ……………………….and has een alloted PF Number ……….……..
B. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995: ((Post allotment of UAN) The UAN alloted or the member is) Please
Tick the Appropriate Option : The KYC details of the above member in the JAN database
Have not been uploaded Have been uploaded but not approved Have been uploaded and approved with DSC
C. In case the person was earlier a member of EPF Scheme, 1952 and EPS 1995;
The KYC details of the above member in the UAN database have been approved with Digital Signature Certificate and transfer request has been
generated on portal
As the DSC of establishment are not registered with EPFO, the member has been informed to file physical claim (Form-13) for transfer of funds from his previous
establishment.
Date : Signate of Employer with Seal of Establishment
