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Form 11 - Revised - Modified Format

The document is a declaration form for employees taking a new job where their previous employer participated in Employees' Provident Funds and Pension schemes, requiring the employee to provide personal information and disclose details about their participation in any previous provident funds or pension schemes. The form is signed by both the new employee to declare the accuracy of the information, and an authorized officer of the new employer to confirm the employee's new appointment details.

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Sundar Rajan Jothimani
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100 views1 page

Form 11 - Revised - Modified Format

The document is a declaration form for employees taking a new job where their previous employer participated in Employees' Provident Funds and Pension schemes, requiring the employee to provide personal information and disclose details about their participation in any previous provident funds or pension schemes. The form is signed by both the new employee to declare the accuracy of the information, and an authorized officer of the new employer to confirm the employee's new appointment details.

Uploaded by

Sundar Rajan Jothimani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Form 11 (Revised)

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (Paragraph 34)


AND
THE EMPLOYEES’ PENSION SCHEME, 1995 (Paragraph 24)
Declaration by a person taking up employment in an establishment in which the Employees’ Provident Funds &
Employees’ Pension Scheme enforce

PERSONAL INFORMATION (MANDATORY)


1. Employee ID: 2. Name:

3. Previous Employer PF Number: 4. Previous Employer EPS Number:

5. UAN: 6. Aadhar:

7. Mobile No: 8. Personal Email id:

I Son/ wife/ daughter of*Sh.


(Name of Employee)
do hereby solemnly declare that :-

(a) I was employed in M/s


(Name and Full Address of the immediate previous employer)
and left service on prior to that, I was employed in
(Date of leaving with immediate previous employer)
from to
(Name and Full Address of the second last employer, if any)
(Date of joining & leaving with second last employer, if any)

(b) I was member of


(Name of PF Trust / Address of PF Office of immediate previous employer )
Provident Fund and also/but not* of the Pension Fund from to

(Date of joining & leaving with immediate previous


employer).
and my account number (s) was/were
(PF No. with Establishment Code of immediate previous employer)

(c) I have / have not* withdrawn the amount of my Provident Fund/Pension Fund.

(d) I have / have not*drawn any superannuation benefits in respect of my past service from any employer.

(e) I have / have never* been a member of any Provident Fund and/or Pension Fund.

(f) I am drawing / not drawing* Pension under EPS 95.

(g) I am a holder / not holder* of scheme Certificate.

(h) Scheme certificate surrendered / not surrendered*.

*Strike out whichever is not applicable.


Date
Signature or left hand thumb
(Date of joining of employee) impression of the employee

Shri/Smt. is appointed as (Designation with Co.)


(Name of Employee)
in
M/s (Name of the present employer ) with effect from
(Date of appointment)

P.F. Account Number


(PF No. with Estt. Code of present employer)

Date

(Date of joining of employee) Signature of the Employer/Manager or Other


Authorised Officer with Office Seal

Form 11

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