Declaration by Person taking Employment in an establishment in which employees Provident Fund Scheme and Family Pension Scheme are in force

I ……………………..................  Son/Daughter/Wife of do hereby (name) solemnly declare that :-

(1) I was last employed (Name and full address of previous employer) and left service on
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(2)  I was member of Employee Provident Fund/Provident Fund maintained by my previous employer which is a recognized Fund under the Employees' Provident Fund Act, 1952/and also /but not  of the Employee's Family Pension Fund from………….to………………and my Provident Fund  Family Pension Fund  Account numbers were…………… and……………… respectively.

(3)  I have/have not  withdrawn my Provident Fund accumulations and the benefit occurring from the Family Pension Fund.

(4)  I have never been a member of any Provident Fund nor Family Pension Fund.

Date:…………

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Signature of employee