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DECLARATION BY A PERSON TAKING UP EMPLOYMENT IN AN ESTABLISHMENT ON WHICH EMPLOYEES’ PROVIDENT FUND
SCHEME,1952AND/OREMPLOYEES’PENSIONSCHEME,1995ISAPPLICABLE.
(PLEASEGOTHROUGHTHEINSTRUCTIONS)
1)NAME (TITLE)
MR. MS. MRS.
(PLEASETICK)
2)DATE OFBIRTH D D M M Y Y Y Y
2 6 0 7 1 9 7 6
3) FATHER’S/HUSBA
ND’SNAME
4) RELATIONSHIPINRESPECTOF(3)ABOVE
(PLEASETICK)
5)GENDER
(PLEASETICK)
MALE FEMALE TRANSGENDER
MALE
6) MOBILE
NUMBER(IF
ANY)
7) EMAILID(IF ANY)
8) WHETHEREARLIERAMEMBEROFTHE EMPLOYEES’PROVIDENTFUNDSCHEME,1952?
(PLEASETICK)
9) WHETHEREARLIERAMEMBEROFTHE
EMPLOYEES’PENSIONSCHEME,1995?(PLEASETI
CK)
DeclarationForm
(ToberetainedbytheEmployerforfuturereference)
Employees’ProvidentFundOrganization
THE EMPLOYEES’PROVIDENTFUNDS SCHEME,1952(PARAGRAPH-34&57)
&
THE EMPLOYEES’PENSIONSCHEME,1995(PARAGRAPH-24)
MR.
M R H E M C H A N D R A P A N D E Y
U M E S H C H A N D R A P A N D E Y
FATHER HUSBAND
9 5 5 7 0 5 6 4 4 5
YES NO
YES NO
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IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT
DETAILSAT (10,11&12):
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B.OTHER DETAILS
A.PREVIOUSEMPLOYMENTDETAILS
10) THEDETAILSOFTHEUNIVERSALACCOUNTNUMBER(UAN)ORPREVIOUSPFMEMBERID:
UAN
OR
PREVIOUSPFMEMBERID REGIONCODE OFFICECODE ESTABLISHMENTID EXTENSION ACCOUNTNUMBER
11) DATE OFEXITFORPREVIOUS
MEMBERID(DD/MM/YYYY)
12) (A)IFSCHEMECERTIFICATEISSUEDFORPREVIOUSEMPLOYMENT,THENSCHEMECERTIFICATENUMBER:
(B)IFPENSION PAYMENTORDER(PPO)ISSUEDFORPREVIOUSEMPLOYMENT,THENPPONUMBER:
13)INTERNATIONALWORKER(PLEASE
TICK)
YES NO
IF THEREPLYTO(13)ABOVEISYES,THEN ENTERTHEDETAILSIN 13(A),13(B)&13(C):
13(A)COUNTRYOFORIGIN(PleaseTick)
INDIA OTHERTHANINDIA(IFYES,PLEASEME
NTIONNAME OFTHECOUNTRY)
13(B)PASSPORTNUMBER
13(C)PASSPORTVALIDFROM
To
14)
EDUCATIONALQ
UALIFICATION
(PLEASE TICK)
ILLITERATE
NON-
MATRIC
MATRIC
SENIORS
ECONDARY GRADUATE
POSTG
RADUATE DOCTOR
TECHNICAL/P
ROFESSIONAL
GRADUATE
15) MARITAL
STATUS(PLEASE
TICK)
16)SPECIALLYABLED
(PLEASETICK)
YES NO IFYES,TICKTHE CATEGORY
LOCOMOTIVE VISUAL HEARING
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
MARRIED UNMARRIED WIDOW/WIDOWER DIVORCEE
MARRIED
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17)KYCDETAILS KYCDOCUMENTTYPE NAMEASON KYCDOCUMENT NUMBER REMARKS,IFANY
BANKACCOUNT-1* HEM CHANDRA PANDEY 10248760272 SBIN0018414
NPR/AADHAAR HEM CHANDRA PANDEY 569988359001
PERMANENT
ACCOUNTNUMBER
(PAN)
HEM CHANDRA PANDEY BFIPP3604R
PASSPORT EXPIRYDATE
DRIVINGLICENCE HEM CHANDRA PANDEY UP25 20002710014 25-06-2030
ELECTION CARD
RATION CARD
ESICCARD
* Mandatory Field (NOTE: BANK ACCOUNT NUMBER (ALONG WITH IFSC CODE) IS MANDATORY.
YOUAREHOWEVERADVISEDTOPROVIDE ALLKYCDOCUMENTSAVAILABLEWITHYOUINADDITIONTOMANDATORY KYCSTO
AVAILBETTERSERVICES.SELF-ATTESTEDPHOTOCOPIESOFTHEDOCUMENTSMUSTBEATTACHEDWITHTHISFORM.
C.UNDERTAKING:
A. ICERTIFY THATALLTHEINFORMATIONGIVENABOVEISTRUETO THEBESTOFMYKNOWLEDGEANDBELIEF.
B. IN CASE,EARLIERAMEMBEROFEPFSCHEME,1952AND/OREPS,1995,
(I) IHAVEENSUREDTHECORRECTNESSOFMY UAN/PREVIOUSPFMEMBERID.
(II) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE
FROMTHE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE
POSSIBLEONLYIFTHEIDENTIFIEDKYC
DETAILSAPPROVEDBYPREVIOUSEMPLOYERHASBEENVERIFIEDBYPRESENTEMPLOYERUSINGHIS
DIGITALSIGNATURECERTIFICATE).
(III) IAMAWARETHATICANSUBMITMYNOMINATIONFORMTHROUGHUANBASEDMEMBERPORTAL.
DATE:
PLACE: SIGNATUREOFMEMBER
A. THEMEMBERMr./Ms./Mrs.……HEM CHANDRA PANDEY……………………..HASJOINEDON
ANDHASBEENALLOTTEDPFMEMBERID
…………………………………………...
B. INCASE THEPERSONWASEARLIERNOTAMEMBEROFEPFSCHEME,1952ANDEPS,1995:
(POSTALLOTMENTOFUAN)THEUANALLOTTEDFORTHEMEMBERIS…………………………
PLEASETICKTHEAPPROPRIATEOPTION:
THEKYCDETAILSOFTHEABOVEMEMBER INTHE UANDATABASE
□ HAVENOTBEENUPLOADED
□ HAVEBEENUPLOADEDBUTNOTAPPROVED
□ HAVEBEENUPLOADEDANDAPPROVEDWITHDSC
C. IN CASETHEPERSON WASEARLIERAMEMBEROFEPFSCHEME,1952ANDEPS,1995:
THEABOVEMEMBERIDOFTHEMEMBERASMENTIONEDIN(A)ABOVEHASBEENTAGGEDWITHHIS/HERUAN/PREVIOUSMEMBER
IDASDECLAREDBYMEMBER.
PLEASETICKTHEAPPROPRIATEOPTION:-
□ THEKYCDETAILSOFTHEABOVEMEMBERINTHEUANDATABASEHAVEBEENAPPROVEDWITHDIGITALSIGNATURECERTIFIC
ATEANDTRANSFERREQUESTHASBEENGENERATEDONPORTAL.
□ ASTHEDSCOFESTABLISHMENTARENOTREGISTEREDWITHEPFO,THEMEMBERHASBEENINFORMEDTOFILEPHYSICALCLAI
M(FORM-13)FORTRANSFER OF FUNDSFROMHISPREVIOUSESTABLISHMENT.
DECLARATIONBYPRESENTEMPLOYER
