New FORM No 11 – Declaration Form

(To be retained by the employer for future reference)

EMPLOYEES’ PROVIDENT FUND ORGANISTION

Employees’ Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees’ Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking upon employment in any establishment on EPF scheme, 1952 and/or EPS, 1995 is applicable)

1 Name of member

2 Father Name

Spouse Name
3 Date of Birth (dd/mm/yyyy)

4 Gender: (Male/Female)

5 Marital Status (Married/Unmarried/Widow/Widower/Divorcee)

6 a) Email ID
b) Mobile No

7 Whether earlier member of Employees Provident Fund YES/NO

Scheme,1952
8 Whether earlier member of Employees Pension Scheme,1995 YES/NO

9 Previous employment details: [if Yes to 7 AND/OR 8 Above]

a) Universal Account Number
b) Previous PF Account Number

c) Date of exit from previous employment : (dd/mm/yyyy)

d) Scheme Certificate No. (If issued)

e) Pension Payment Order (PPO) No (If issued)

10 a) International Worker

b) If yes, state country of origin (India/Name of other country)

c) Passport No

d) Validity of passport [(dd/mm/yyyy) to (dd/mm/yyyy)]

11 KYC details : (attest self attested copies of following KYCs)

a) Bank Account No & IFS Code

b) Aadhaar Number

c) Permanent Account Number (PAN) If available

 UNDER TAKING

1) Certified that the particulars are true to the best of my knowledge.

2) I authorize EPFO to use my Aadhaar for verification/authentication/eKYC purpose for service

delivery.

3) Kindly transfer the funds and service details, if applicable, from the previous PF accounts as
declared above to the present [Link]
(The transfer would be possible only if the identified KYC detail approved by previous
employer has been verified by present employer using the Digital Signature Certificate)

4) In case of changes in the above details, the same will be intimated to the employer at the
earliest.

Date:
Place: Signature of member

DECLARATION BY PRESENT EMPLOYER

A. The member Mr./Ms./Mrs……………………………has joined on ………………….and has

been allotted 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 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
▪ Have been uploaded but not approved
▪ Have not uploaded and approved with DSC
C. In case the person was earlier a member of EPF scheme 1952, EPS, 1995:
• The above PF account number/UAN of the member as mentioned in (A) above
has been tagged with his/her UAN/ Previous member ID as declared by member.
• Please tick appropriate option:-
• 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:

Signature of Employer with seal of establishment

 (FORM 2 REVISED)

NOMINATION AND DECLARATION FORM FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS

Declaration and Nomination Form under the Employees Provident Funds and Employees Pension Schemes
(Paragraph 33 and 61 (1) of the Employees Provident Fund Scheme 1952 and Paragraph 18 of the Employees
Pension Scheme 1995)

1. Name (IN BLOCK LETTERS) : _______________________________________________________________________________

Name Father’s / Husband’s Name Surname

2. Date of Birth : ___________________ 3. Account No. ___________________

4. *Sex : MALE/FEMALE: ______________________ 5. Marital Status ________________________________________

6. Address Permanent / Temporary : _____________________________________________________________________________

________________________________________________________________________________

PART – A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s) mentioned below
to receive the amount standing to my credit in the Employees Provident Fund, in the event of my death.
If the nominee is minor
Name of the Address Nominee’s Date of Total amount or share of name and address of the
Nominee (s) relationship with Birth accumulations in guardian who may receive
the member Provident Funds to be the amount during the
paid to each nominee minority of the nominee

1 2 3 4 5 6

1 *Certified that I have no family as defined in para 2 (g) of the Employees Provident Fund Scheme 1952 and should I
acquire a family hereafter the above nomination should be deemed as cancelled.

2. * Certified that my father/mother is/are dependent upon me.

Strike out whichever is not applicable Signature/or thumb impression

of the subscriber

PART – (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow/Children Pension in the
event of my premature death in service.

Sr. No Name & Address of the Family Member Age Relationship with the member

(1) (2) (3) (4)

Certified that I have no family as defined in para 2 (vii) of the Employees’s Family Pension Scheme 1995 and should I acquire a
family hereafter I shall furnish Particulars there on in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para 16 2 (a) (i) & (ii) in the
event of my death without leaving any eligible family member for receiving pension.

Name and Address of Date of Birth Relationship with member

the nominee

Date ___________________

Signature or thumb impression

of the subscriber

____________________________________________________________________________________________________________

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri / Smt./
Miss_________________________________________________________________ employed in my establishment after he/she has
read the entries / the entries have been read over to him/her by me and got confirmed by him/her.

Date : _____________________ Signature of the employer or other authorised officer of the

establishment

Place :
Name & address of the Factory /Establishment
Date :
 Confidential

FORM - F
(See Sub-Rule (1) of Rule 6)

NOMINATION

I Shri/Smt./Kumari.......................................................................whose particulars are given in the

statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable
after my death as also the gratuity standing to my credit in the event of my death before that
amount has become payable or having become payable has not been paid and direct that the said
amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).
2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the
meaning of clause (h) of Section 2 of the Payment of gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section 2 of the said
act.

4. (a) My father/mother/parents is/are not dependent on me.

(b) My husband's father/mother/parents is/are not dependent on my husband.

5. I have excluded my husband from my family by a notice dated the ________________ to the
Controlling Authority in terms of the proviso to clause (h) of Section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)
Name in full with full Relationship with Age of Proportion by which the
address of nominee(s) the employee nominee gratuity will be shared

Statement
1. Name of employee in full :
2. Sex :
3. Religion :
4. Whether unmarried/married/widow/widower :
5. Department / branch/Section where employed :
6. Post held with Ticket or Serial No., if any :
7. Date of appointment :
8. Permanent address :

Village _____________________ Thana _____________ Sub-division ______________

Post office __________________ District ____________ State ___________________

Place : Signature / Thumb-impression

Date : of the employee:
 Confidential

Declaration by witnesses
Fresh nomination signed / thumb-impressed before me.

Name in full and full Signature of witnesses

Address of witnesses

1. 1.

2. 2.

Place:
Date:
Certificate by the employer
Certified that the particulars of the above nomination have been verified and recorded in this
establishment.

Employer’s reference No., if any.

Date:
Signature of the employer / officer
Authorised designation

Authorised Signatory
Name & Address of the establishment /
Rubber-stamp thereof
Acknowledgment by the employee

Received the duplicate copy of nomination in Form F filed by me and duly certified by the
employer.

Date: Signature of the employee

Note: Strike out the words/paragraphs not applicable.