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(3) I have/have not withdrawn my Provident Fund accumulations and the benefit occurring from the Family Pension Fund.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