New Form No.
-11 - Declaration Form
(To be retained by the employer for futurereference)
FORM 11 EMPLOYEES' PROVIDENT FUNDORGANISATION
Employees' Provident Funds Scheme, 1952 (Paragraph 34 & 57) &
Employees' Pension Scheme, 1995 (Paragraph 24)
(Declaration by a person taking up employment in any establishment on which EPF Scheme, 1952 and /or EPS, 1995 is applicable)
1 Name of the member Rahul Sharma
Father's Name Spouse's Name
2
(Please tick whichever is applicable)
Neeta Sharma
3 Date of Birth: (DD / MM / YYYY) 26/06/1985
4 Gender: (Male/Female/Transgender) Male
5 Marital Status: (Married/Unmarried/Widow/Widower/Divorcee) Married
(a) Email ID: [Link]@[Link]
6
(b) Mobile No.: 9892294350
Whether earlier a member of Employees' Provident Fund NYoes/ No
7
Scheme, 1952
8 Whether earlier a member of Employees' Pension Scheme, 1995 YNoes / No
Previous employment details: [If yes to 7 AND/OR 8 above]
(a) Universal Account Number: 100937368
(b) Previous PF Account Number: MHBAN0024506
9
(c) Date of exit from previous employment: (DD/MM/YYYY)
(d) Scheme Certificate No. (if issued)
(e) Pension Payment Order (PPO) No. (if issued)
(a) International Worker: No
(b) If yes, state country of origin (India/Name of other country)
10
(c) Passport No.
(d) Validity of Passport [(DD/MM/YYYY) to (DD/MM/YYYY)]
KYC Details: (attach self attested copies of following KYCs)
a) Bank Account No. & IFS Code 135780903989 135780903989
(Bank A/C No.) (IFSC Code)
11
b) AADHAR Number 1257 0283 8332
c) Permanent Account Number (PAN), if available BCUPG9112P
UNDERTAKING
1) Certified that the particulars are true to the best of my knowledge.
2) I authorize EPFO to use my AADHAR for verification/authentication/eKYC purpose for service delivery.
3) Kindly transfer the funds and service details, if applicable, from the previous PF account as declared above to the present P.F. Account.
(The transfer would be possible only if the identified KYC detail approved by previous employer has been verified by present employer
using his Digital Signature Certificate) Your Signature
4) In case of changes in above details, the same will be intimated to employer at the earliest.
Date: 26/ 02/ 2021
Place: Mumbai Signature of Member
DECLARATION BY PRESENTEMPLOYER
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 been uploaded and approved with DSC
A. In case the person was earlier a member of EPF Scheme, 1952 and 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 the 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 pervious establishment.
Date: Signature of Employer with Seal of Establishment
FORM F – Gratuity
Piramal
Rahul Sharma
Neeta Sharma Wife 32 50%
Mukesh Sharma Father 66 50%
Please note, Only immediate family members – If one nominee – 100 %
Parents/Spouse can be nominated. If more than one nominee – total
Minors/ Other relatives cannot be nominated proportion should be 100%
Rahul Sharma
Male
Hindu
Married
301 – A wing, 3rd Floor, Labh Siddhi Society, Bandra (west),
Mumbai 400070
FORM F – Gratuity
Page 2
Your Signature
Mumbai Maharashtra
Mumbai
26/02/2021
Your Signature
FORM 2 – PF NOMINATION
FORM 2 (REVISED)
Date of Appointment:
Group No.:
PF Deduction date:
Office:
UAN No: 100500600831
NOMINATION AND DECLACTION FORM
FOR UNEXEMPTED/EXEMPTED ESTABLISHMENTS
Declaration and Nomination Form under the Employee’s Pr ovident Funds & Employee’s Pension Scheme
(Paragraph 33 & 61(1) of the Employees’ Provident Fund Scheme, 1952 & Paragraph 18 of the Employee’s Pension
Scheme, 1995)
Rahul Sharma
1. Name (In Blo ck Letters) :
2. Father’s /Husband’s Name :
Mukesh Sharma
3. Date of Birth : 26/06/1985 4. Sex Male
(Male/Female)
5. Marital Status : Married
(married /unmarried /widow/ widower)
6. PF Acc ount No. TD/CAL/1678246/010/0311036
7. Address: 301 – A wing, 3rd Floor, Labh Siddhi Society, Bandra (west),
Mumbai 400070, Maharashtra
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 Employee’s Provident Fund in the event of my
death:
Total amount
Nominee’s Date of
of share of
relationshi Birth If the nominee is a minor,
accumulation
p with the name & relationship &
s in Provident
member address of the guardian who
Name & Address of the Nominee (s) Fund to be
may receive the amount
paid to each
during the minority of
nominee
nominee
(1) (2) (3) (4) (5)
Neeta Sharma Wife 20/ 8/ 1989 50%
Mukesh Sharma Father 15/ 7/ 1955 50%
Please note, Only immediate family members – Parents/Spouse can be nominated.
Minors/ Other relatives cannot be nominated
1. i. Certified that I have no family as defined in para 2(g) of the Employee’s Provident Fund Scheme, 1952 and
should I a c quire a family hereafter the above nomination should be deemed as c ancelled.
Your Signature
2. i. Certified that my father/ mother is/ are dependent upon me.
(i) Strike out whichever is not applicable
Signature or thumb impression of the subscriber
(P. T. O.)
FORM 2 – PF NOMINATION
(Part B)
PART – B (EPS)
Para 18
I hereby furnish below particulars of the members of my family who would be eligible to re ceive widow / children Pension
in the event of my death.
Sr. Name & Address of the family member/ s Date of Birth Relationship with member
No.
(1) (2) (3) (4)
Neeta Sharma 20/ 8/ 1989 Wife
Mukesh Sharma 15/ 7/ 1955 Father
i. i Certified that I have no family, as defined in para 2(vii) of the Employees’ Pension Scheme, 1995 and should I
acquired a family hereafter I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension (admissible under para
Mention 16 (i)details
Same & (ii) in in
theBoth Blocks
event of my death without leaving any eligible member/s for receiving pension.
Sr. Name & Address of the Nominee Address Date of Birth Relationship with member
No.
(1) (2) (3) (4)
Neeta Sharma Mumbai 20/ 8/ 1989 Wife
Mukesh Sharma Mumbai 15/ 7/ 1955 Father
Your Signature
Date 26/ 02/ 2021
(i) Strike out whichever is notapplicable Signature or thumb impression of the subscriber
CERTIFICATE BYEMPLOYER
Certified that the above declaration and nomination has be en signed / thumb impressed before my by Shri/Smt./Kum.
employed in my establishment after he/she has
read the entries/ entries have been read over to him / her by me and got confirmed by him / her.
Place
Signature of the employer or other Authorized
Officer’s of the establishment signature with designation
(name & address of the fa ctory /e stt. or rubber stamp thereof)