Page 1 : Form No. 11 (New), Declaration Form, , (To be retained by the Employer for future reference), , Employees’ Provident Fund Organization, , THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 (PARAGRAPH-34 & 57), &, THE EMPLOYEES’ PENSION ScHEME, 1995 (PARAGRAPH-24), , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1) Name — (Tme) viz]s Tulwlals] Te T | aan, i | | |, (PLEASE TICK) | | | ., 2) DATE oF BIRTH D/O|/m|m/[yYliyly ‘al, 5 Slila falz |, i T, 3) FaTHer’s/ me ]1C |HIAlviolria | fs|Hlellale| |v, HUSBAND'S NAME t, |, ! |, 4) RELATIONSHIP IN RESPECT OF (3) ABOVE FATHER HusBAND, (PLEASE Tick) 4, 5) GENDER MALE FEMALE | TRANSGENDER, (PLEASE TICK) es, MOBILE NUMBER, * (IF any) Sa fh 12 SON Ne Gola Sg, 7) EMAIL ID (IF ANY) vii iS Pra We jig Vil ke NF Ne rm Q, , , , >, , 4+ 1@/a@|m t{.1¢ | olm, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 8) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952?, (PLEASE Tick) | YES | NO, 9) WHETHER EARLIER A MEMBER OF THE EMPLOYEES’ PENSION SCHEME, 1995?, , (PiesseTia) [YES 71 no [TT], , IF RESPONSE TO ANY OR BOTH OF (8) & (9) ABOVE 1S VES, THEN MANDATORILY FILL UP THE PREVIOUS EMPLOYMENT DETAIL, AT (10,118 12):, Page 1 of 3

Page 2 : REVIOUS EMPLOYMENT DETAILS, 10). 1HE DETAILS OF THE UNIVERSAL ACCOUNT NUMBER (UAN) OR PREVIOUS PF MEMBER ID:, , , , , , , , , , , , , , , , , , , , e eee 2 a Tele Tels leis, Pn EVIOUS PF MEMBER ID ReGIon Cone | Orrice Cont ESTABLISHMENT ID EXTENSION | Account NuM@ei, 12> (ere oF Exit ror previous | D D M M | ¥ Y Y Y |, , M=mBER ID (DD/MM/YYYY), , , , , , , , , , , , , , , , , , , , , , 17) £4) IF SCHEME CERTIFICATE ISSUED FOR PREVIOUS EMPLOYMENT, THEN SCHEME CERTIFICATE NUMBER:, <) IF PENSION PAYMENT ORDER (PPO) ISSUED FOR PREVIOUS EMPLOYMENT, THEN PPO NUMBER:, , B. CHER DETAILS, , 13) INTERNATIONAL WorKER, (PLEASE TICk), , IF THE REPLY TO (1 3) ABOVE IS YES, THEN ENTER THE DI, , , , , , 13(A) COUNTRY OF ORIGIN (Please Tick), , So, , ETAILS IN 13(A), 13(B) & 13(c):, , , , INDIA, , OTHER THAN INDIA (IF YES, PLEASE, MENTION NAME OF THE COUNTRY), , , , , , , , , , 13(B) PASSPORT NUMBER, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , See, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 13(C) PASSPORT VALID FROM DIDIMIMTY TY 7, To bao [apathy Ty ]yy]y, Non- SENIOR Post TECHNICAL, Ye Gudiece TULITERATE | waatpic | MATRIC | seconpary | GRADUATE | Grapyare | DOCTOR PROrESee, (PLEASE TICK) er, 15) MARITAL STATUS MARRIED Unmarried | WiDOW/ WIDOWER | DivorcEE, (PLEASE TICK) CO iil rT, 16) SPECIALLY ABLED YES No IF YES, TICK THE CATEGORY, (PLEASE TICK) TI 4 LOCOMOTIVE VISUAL HEARING, , , , , , , , , , a, , , , , , , , , , , , , , , , , , , , , , , , Page 2 of 3

Page 3 : 7) wYC DeTAns KYC DOCUMENT TYPE NAME AS ON KYC DOCUMENT NUMBER ,_ REMARKS, IF ANY, BANK ACCOUNT-1* VISHWAS Ale: 06425 volo5#6 sau | TS? kKARB OOF, NPR/AADHAAR ViSHWAS.C $059 5240 6202, PERMANENT ACCOUNT, Numer (PAN) VISHWAS C CO2ZPV09 974, PassPORT, DRIVING LICENCE, ELECTION CARD, RATION CARD, ESIC Carp, * Mandatory Field (NOTE: BANK AccouNT NUMBER (ALONG WITH IFSC CODE) 1S MANDATORY. YOU, ARE HOWEVER ADVISED TO PROVIDE ALL KYC DOCUMENTS AVAILABLE WITH YOU IN ADDITION TO MANDATORY KYCs TO, AVAIL BETTER SERVICES. SELF-ATTESTED PHOTOCOPIES OF THE DOCUMENTS MUST BE ATTACHED WITH THIS FORM., , , , , , , , C. UNDERTAKING:, , A. 1 CERTIFY THAT ALL THE INFORMATION GIVEN ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF., B. INCASE, EARLIER A MEMBER OF EPF SCHEME, 1952 AND/OR EPS, 1995,, (1) I HAVE ENSURED THE CORRECTNESS OF MY UAN/ PREVIOUS PF MEMBER ID., (11) THIS MAY ALSO BE TREATED AS MY REQUEST FOR TRANSFER OF FUNDS AND SERVICE DETAILS IF APPLICABLE FROM, THE PREVIOUS ACCOUNT AS DECLARED ABOVE TO THE PRESENT P.F. ACCOUNT. (THE TRANSFER WOULD BE POSSIBLE, ONLY IF THE IDENTIFIED KYC DETAILS APPROVED BY PREVIOUS EMPLOYER HAS BEEN VERIFIED BY PRESENT, EMPLOYER USING HIS DIGITAL SIGNATURE CERTIFICATE)., (111) 1 AM AWARE THAT I CAN SUBMIT MY NOMINATION FORM THROUGH UAN BASED MEMBER PORTAL., , =6 nwt, pare: 23/0cT/2021 CNIS, piact: Bang love SIGNATURE OF MEMBER, , DECLARATION BY PRESENT EMPLOYER, A. THE MEMBER Mr./Ms-fMrs. ....¥ tS ht, conve NESE AGERE, 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 1S, * PLEASE TICK THE APPROPRIATE OPTION:, THE KYC DETAILS OF THE ABOVE MEMBER IN THE UAN DATABASE, 1 _ HAVE NOT BEEN UPLOADED, [ _ HAVE BEEN UPLOADED BUT NOT APPROVED, (1 _ HAVE BEEN UPLOADED AND APPROVED WITH DSC, (64 IN CASE THE PERSON WAS EARLIER A MEMBER OF EPF SCHEME, 1952 AND EPS, 1995:, © THE ABOVE MEMBER ID 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., TAS 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., , (veer, pare: 24locr/202) SIGNATURE OF EMPLOYER WITH SEAL OF ESTABLISHMENT, Page 3 of 3

Page 4 : a, , b, , Instructions for filling up Declaration Form, , Form to be filled in the language of the form, , Each box, wherever provided, should contain only one character (alphabet /number, , /punctuation sign) leaving 2 blank box after each word, , The item-wise instructions to fill up the form are as follow, , 1. Please tick the Title (Mr/Ms/Mrs) and write full name in the form in Item No 1. It is, reiterated that each box should contain only one character leaving a biank box after each, word. it may please be noted that the Title (Mr/Ms/Mrs) should not b¢ entered again in, the boxes provided to write full name, , 2. Please provide Date of Birth in the form (DD/MM/YYYY) in Item No 2, , 3. Please provide Father's / Husband's Name in full in the form in ttem No 3. It may please, be noted that the Title (Mr/Sh.) should not be entered again in the boxes provided to, write full name, , 4. Please tick the relevant box in item no 4 based on Item no 3. Tell the relationship i.e, Father or Husband, Please Tick the relevant Box in Item No S, , 6 Please provide your mobile number on which formal communication can be established, and necessary information can be provided through S.M.S to the member in Item No6, , 7. Please provide e-mail id on which formal communication can be established and, necessary information can be provided through e-mails to the member in item No 7, , 8. Please tick ‘YES’ if you have previous membership of the Employees’ Provident Fund, Scheme, 1952 otherwise ‘NO’ in Item No 8, which is a mandatory field, , 9. Please tick ‘YES’ if you have previous membership of the Employees’ Pension Scheme,, 1995 otherwise ‘NO’ in Item No 9, which is a mandatory field., , have ticke ” in any or both of (8) & (9) above, please follow points 10, 11, & 12, , to fill up the previgus employment details ot Item Numbers 10.11 &12, otherwise follow, , jis is very important and shoul: ed with utmost care as a number, of services including tagging of various member (Ds with VAN and its portability are, ej a Si ils., , 10. Please fill Universal Account Number (UAN) Or Previous employment P.F. member 1D in, Item No (10)., * UAN is 12 digit number which has been allotted by EPFO and provided to the EPF, member through employer. To check whether you have been allotted UAN against, ne, capo

Page 5 : 11, , 12, , 13, , 14., AS:, 16., , Ti., , your PF member 1D, please go to the UAN Member e-sewa on EPFO website, , www.epfindia.gov.in and click on Know your UAN status, , ¢ Previous employment P.F. member ID is to be furnished in the boxes as, , REGIONCODE OFFiCECODE | FSTABLISHMENTID EXTENSION == ACcoU' 3ER, , For instance, the number MH/BAN/i2345/123 has to entered as, , | MH | BAN 12345 000 123, and the number MH/BAN/12345/A/123 has to entered as, | MH "| BAN 12345 OOA 123, , Please fill Date of Exit (i.e. Date on which member has ceased to work in the previous, establishment) for the previous employment in Item No. 11, , Please provide the details of Scheme Certificate in Item No. 12 (A} and Pension Payment, Order in Item No. 12 (B), if the same have been issued to the member for the previous, membership, , Please tick the relevant box in Item No. 13. \f you are international worker then fill the, boxes 13(A), 13(B) & 13(C) i.e. please provide country of origin in 13(A), Passport Number, in 13(B) and validity period of Passport in 13(C), , Please tick the relevant Box for educational qualification in Item No. 14, , Please provide marital Status by ticking the relevant Box in ttem No. 15, , Please tick the relevant box for handicap status in Item No. 16. If response to this item is, YES, please tick the relevant category in the adjacent box., , Please provide ‘Know Your Customer (KYC)’ details of all the available documents, mentioned in this column as far as possible. Bank account Number with I.F.S C. code is, mandatory. Fill the name as on KYC with KYC Number and also the remarks in item No 17, Remarks column is to fill up the relevant details i.e. |.F.S.C. code in case of Bank account, Number, ‘Valid up to’ date in case of Passport, date of expiry in case of driving license., , it is very important to note that KYC details are required to provide better services to the, members and hence details of maximum number of documents should be provided in, the Item No. 17., , Please put your signature in the space provided with date and place Please submit the filled, , up form to the present employer., , The present employer is required to take necessary action as explained in detail on EPFO, , website under UAN services and fill up the necessary details with his signature, designation, , and seal in the space provided. Nia, , gotta \202 \