FORM 11(New) – Declaration Form

EPF Declaration Form
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)
1. Name of Member (Aadhar Name)
2. Father’s Name / Spouse’s Name
(Please tick whichever applicable)
3. Date of Birth (dd/mm/yyyy)
4. Gender (Male / Female / Transgender)
5. Marital Status? (Single/Married/Widow/Widower/Divorcee)
6. Contact Details
7. Previous EPF Membership
8. Previous Employment Details
9. International Worker Details
10. a) Are you an International Worker?
b) If Yes, state country of origin
c) Passport Number
d) Validity of Passport (dd/mm/yyyy to dd/mm/yyyy)
11. KYC Details (attach self-attested copies of the following documents): Answer
a) Bank Account Number & IFSC Code
b) Aadhaar Number
c) Permanent Account Number (PAN)
12. Employment Details
First EPF Member Enrolled Date First Employment EPF Wages Are you EPF Member before 01/09/2014 If Yes, EPF Amount Withdrawn? If Yes, EPS (Pension) Amount Withdrawn? After Sep 2014 earned EPS (Pension) Amount Withdrawn before Join current Employer?
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.
Date: _________________

Place: _________________              Signature of Member: _________________
DECLARATION BY PRESENT EMPLOYER
  1. The member Mr./Ms./Mrs. ……………………… has joined on ……………………… and has been allotted PF Number ………………………
  2. In case the person was earlier not a member of EPF Scheme, 1952 and EPS, 1995:
  3. The KYC details of the above member in the UAN database:
  4. [ ] Have not been uploaded
  5. [ ] Have been uploaded but not approved
  6. [ ] Have been uploaded and approved with DSC
Date: _________________            Signature of Employer with Seal of Establishment: _________________