Fillable Printable Employees' Provident Fund Organization
Fillable Printable Employees' Provident Fund Organization
Employees' Provident Fund Organization
Page 1 of 3
D
ECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH
E
MPLOYEES
’
P
ROVIDENT
F
UND
S
CHEME
,
1952 AND/OR EMPLOYEES’ PENSION SCHEME, 1995 IS APPLICABLE.
(PLEASE GO THROUGH THE INSTRUCTIONS)
1)
NAME (TITLE)
M
R
. M
S
. M
RS
.
(PLEASE TICK)
2)
DATE OF BIRTH
D D M M Y Y Y Y
3)
FATHER’S/
HUSBAND’S NAME
M
R
.
4)
RELATIONSHIP IN RESPECT OF (3) ABOVE
(P
LEASE
T
ICK
)
F
ATHER
H
USBAND
5)
GENDER
(P
LEASE
T
ICK
)
MALE FEMALE TRANSGENDER
6)
MOBILE NUMBER
(I
F ANY
)
7)
EMAIL ID (IF ANY)
8)
WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952 ?
(PLEASE TICK)
9)
WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995?
(PLEASE TICK)
IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILS
AT
(10,11&12):
YES NO
YES NO
Employees’ Provident Fund Organization
T
HE
E
MPLOYEES
’
P
ROVIDENT
F
UNDS
S
CHEME
,
1952
(P
ARAGRAPH
-34
&
57)
&
T
HE
E
MPLOYEES
’
P
ENSION
S
CHEME
,
1995
(P
ARAGRAPH
-24)
Declaration Form
(To be retained by the Employer for future reference)
Page 2 of 3
A.
PREVIOUS EMPLOYMENT DETAILS
10)
THE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:
UAN
OR
PREVIOUS PF MEMBER ID
R
EGION
C
ODE
O
FFICE
C
ODE
E
STABLISHMENT
ID
E
XTENSION
A
CCOUNT
N
UMBER
11)
DATE OF EXIT FOR PREVIOUS
MEMBER ID (DD/MM/YYYY)
D D M M Y Y Y Y
12)
(A) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:___________
(
B
)
I
F PENSION PAYMENT ORDER
(PPO)
ISSUED FOR PREVIOUS EMPLOYMENT
,
THEN
PPO
NUMBER
:______________
B.
OTHER DETAILS
13)
I
NTERNATIONAL
W
ORKER
(PLEASE TICK)
Y
ES
N
O
IF THE REPLY TO (13) ABOVE IS YES, THEN ENTER THE DETAILS IN 13(A), 13(B) & 13(C):
13(A) COUNTRY OF ORIGIN (Please Tick)
INDIA OTHER THAN INDIA (IF YES, PLEASE
MENTION NAME OF THE COUNTRY)
13(B) PASSPORT NUMBER ______________________________
13(
C
)
P
ASSPORT VALID FROM
To
14)
EDUCATIONAL
QUALIFICATION
(P
LEASE TICK
)
I
LLITERATE
NON-
MATRIC
M
ATRIC
SENIOR
SECONDARY
G
RADUATE
POST
GRADUATE
D
OCTOR
TECHNICAL/
PROFESSIONAL
15)
MARITAL STATUS
(PLEASE TICK)
MARRIED UNMARRIED WIDOW/ WIDOWER DIVORCEE
16)
S
PECIALLY ABLED
(PLEASE TICK)
YES NO IF YES, TICK THE CATEGORY
L
OCOMOTIVE
V
ISUAL
H
EARING
D D M M Y Y Y Y
D D M M Y Y Y Y
Page 3 of 3
17)
KYC DETAILS
KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER REMARKS, IF ANY
BANK ACCOUNT-1* IFSC CODE*
NPR/AADHAAR
PERMANENT ACCOUNT
NUMBER (PAN)
PASSPORT EXPIRY DATE
D
RIVING
L
ICENCE
E
XPIRY
D
ATE
ELECTION CARD
R
ATION
C
ARD
ESIC CARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY. YOU
ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCS TO
AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM.
C.
UNDERTAKING:
A.
I
CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF
.
B.
IN CASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,
(
I
)
I
HAVE ENSURED THE CORRECTNESS OF MY
UAN/
PREVIOUS
PF
MEMBER ID
.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM
THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE
ONLY IF THE IDENTIFIED
KYC
DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT
EMPLOYER USING HIS
D
IGITAL
S
IGNATURE
C
ERTIFICATE
).
(III) I AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL.
DATE:
PLACE: SIGNATURE OF MEMBER
DECLARATION BY PRESENT EMPLOYER
A.
T
HE MEMBER
Mr./Ms./Mrs. …………………………..
HAS JOINED ON
…………………..
AND HAS BEEN ALLOTTED
PF
MEMBER ID
…………………………………………...
B.
IN CASE THE PERSON WAS EARLIER NOT A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:
(P
OST ALLOTMENT OF
UAN)
T
HE
UAN
ALLOTTED FOR THE MEMBER IS
…………………………
PLEASE TICK THE APPROPRIATE OPTION:
THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE
□
HAVE NOT BEEN UPLOADED
□
H
AVE 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:
T
HE ABOVE MEMBER ID OF THE MEMBER AS MENTIONED IN
(A)
ABOVE HAS BEEN TAGGED WITH HIS
/
HER
UAN/P
REVIOUS
MEMBER ID AS DECLARED BY MEMBER.
PLEASE TICK THE APPROPRIATE OPTION:-
□
T
HE
KYC
DETAILS OF THE ABOVE MEMBER IN THE
UAN
DATABASE HAVE BEEN APPROVED WITH
D
IGITAL
SIGNATURE CERTIFICATE AND TRANSFER REQUEST HAS BEEN GENERATED ON PORTAL.
□
A
S THE
DSC
OF ESTABLISHMENT ARE NOT REGISTERED WITH
EPFO,
THE MEMBER HAS BEEN INFORMED TO FILE
PHYSICAL CLAIM
(F
ORM
-13)
FOR TRANSFER OF FUNDS FROM HIS PREVIOUS ESTABLISHMENT
.
DATE: SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT
