PF_Declartion_Form (1).docx
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This document is a 3 page declaration form for a new employee taking up employment where an Employees' Provident Fund applies. It collects personal details of the employee like name, date of birth, gender, previous PF details if applicable. It also collects KYC documents and a signed declaration from both the employee and the new employer.
PF_Declartion_Form (1).docx
- 1. Page1of3 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
- 2. Page2of3 IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE IS YES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAILSAT (10,11&12):
- 3. Page3of3 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
- 4. Page4of3 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