(On letter Head of the Establishment)

Joint Declara on Form

I ___________________________________
BISWAJIT RANA having UAN _______________________________,
100608226620
PF account _______________________________and
WBPRB00400960000006202 Aadhaar __________________________
4861 5742 6469
is/was the employee of establishment M/S. SHOMUK
___________________________________________.
ENGINEERING - CONSULTANCY SERVICES
The personal details furnished to EPFO earlier were found to be incorrect /blank, and therefore
request for change/updation in the member profile as follows.
S. No. Details/particulars Incorrect details Correct details
1 Aadhaar
4861 5742 6469
2 Name BISWAJIT RANA
3 DOB
04/03/1992
4 Gender
MALE
5 Fathers/Mothers JUGAL RANA
6 Relationship
FATHER
7 DOJ Not Available 01/04/2015
8 DOL Not Available 31/01/2016
9 Reason of leaving
CESSATION SHORT SERVICE
10 Marital Status
UNMARRIED
11 Nationality INDIAN

I_________________________________S/o_______________________ authorized signatory of

the establishment, have verified the request, document attached and the records of the establishment
and certify that the facts mentioned above are correct. I am also
enclosing_______________________________, _________________________________ and
_________________________ (documents of Establishment) in support of the request of the
employee mentioned above.

BISWAJIT RANA
We____________________________________(Employee) and __________________________
(Authorized Signatory) hereby declare we have not concealed any facts and the above-mentioned
facts are correct. We also indemnify that in case of wrong payment/over payment/under payment
because of the above furnished information shall be jointly held responsible.

BISWAJIT RANA
Authorized signatory Name & Signature of the member
 FORM - 5 ( P.S.)
THE EMPLOYEES PENSION SCHEME, 1995 (PARA 20 (2))
THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 PARA 36[ 2 ] (a) & (b)
RETURN OF ADDITIONS FOR THE MONTH
Part 'A' Details of employee's qualifying for membership of the fund for the first time

:
NAME AND SHOMUK ENGINEERING - CONSULTANCY SERVICES
ADDRESS OF 5A, PALM AVENUE PARK STREET CODE NO OF THE WBPRB0040096000
FACTORY ESTT.
THE ESTT.

Total period of
Date of eligiblity for
previous service [
NAME OF THE EMPLOYEE [ IN FATHER'S NAME / new member / date
S.NO. A/C NO. DATE SEX excluding period of Remarks
BLOCK LETTERS] HUSBAND'S NAME OF of joining the Estt
breaks as on the date
BIRTH in case of member
of joining the fund
1 2 3 4 5 6 7 8 9

1 6202 BISWAJIT RANA JUGAL RANA 04/03/1992 MALE 01/04/2015

DATE: Signature of the employer or other authorised officer and stamp of the estt.
………………………………………………………………………………………………………………………………………………………………………………….
FORM: 10
THE EMPLOYEES PENSION SCHEME, 1995 (PARA 20 (2))
THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 PARA 36[ 2 ] (a) & (b)

NAME AND SHOMUK ENGINEERING - CONSULTANCY SERVICES

CODE NO OF THE
ADDRESS OF 5A, PALM AVENUE PARK STREET WBPRB0040096000
FACTORY ESTT.
THE ESTT.

NAME OF THE EMPLOYEE [ IN FATHER'S NAME / DATE OF REASON FOR LEAVING

S.NO. A/C NO. REMARKS
BLOCK LETTERS] HUSBAND'S NAME LEAVING SERVICE

1 2 3 4 5 6 7

1 6202 BISWAJIT RANA JUGAL RANA 31/01/2016 CESSATION SHORT SERVICE

DATE: Signature of the employer or other authorised officer and stamp of the estt.
NOTE:Please state weather the member is (a) retiring according to papr 69(1)(a) or (b) of the scheme (b) leaving India for permanent settlement abroad( c ) retenchment(d) permanent & total
disablement due to employement injury(e) discharged(f) resiging from or leaving service(g) taking up employment somewhere ( h) death (i) attained age of 58 years

Certified that the member mentioned at S.No. ___ Mr. / Mrs/ Miss _______________________ was not paid / paid retrenchment
SIGNATURE OF THE EMPLOYER
compansation of Rs.__________ under Ind. Dispute.Act 1947
 lnL; iklcqd / Member Passbook
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
LFkkiuk vkbZMh@uke | Establishment ID/Name WBPRB0040096000 / SHOMUK ENGINEERING - CONSULTANCY SERVICES
lnL; vkbZMh@uke | Member ID/Name WBPRB00400960000006202 / BISWAJIT RANA
tUe frfFk | Date of Birth 04-03-1992
;w , u | UAN 100608226620

bZih,Q iklcqd [ foÙkh; o"kZ - 2015-2016 ] / EPF Passbook [ Financial Year - 2015-2016 ]
deZpkjh 'ks"k / fu;ksäk 'ks"k / isa'ku 'ks"k /
fooj.k / Particulars Employee Employer Pension
Balance Balance Balance
OB Int. Updated upto 31/03/2015 0 0 0
VªkalD'ku / Transaction osru / Wages va'knku / Contribution
osru ekg /
Wage Month çdkj fooj.k / Particulars deZpkjh / fu;ksäk / isa'ku /
fnuk¡d / Date / Type bZ ih ,Q / EPF bZ ih ,l / EPS Employee Employer Pension
Apr-2015 08-06-2015 CR Cont. For Due-Month 052015 8,112 8,112 973 297 676
May-2015 11-08-2015 CR Cont. For Due-Month 062015 8,112 8,112 973 297 676
Jun-2015 06-08-2015 CR Cont. For Due-Month 072015 8,528 8,528 1,023 313 710
Jul-2015 07-09-2015 CR Cont. (others) 624 0 75 23 52
Jul-2015 07-09-2015 CR Cont. For Due-Month 082015 8,528 8,528 1,023 313 710
Aug-2015 07-10-2015 CR Cont. For Due-Month 092015 8,528 8,528 1,023 313 710
Sep-2015 09-11-2015 CR Cont. For Due-Month 102015 8,528 8,528 1,023 313 710
Oct-2015 07-12-2015 CR Cont. For Due-Month 112015 8,528 8,528 1,023 313 710
Nov-2015 06-01-2016 CR Cont. For Due-Month 122015 7,959 7,959 955 292 663
Dec-2015 08-03-2016 CR Cont. For Due-Month 012016 5,502 5,502 660 202 458
Jan-2016 31-03-2016 CR Cont. For Due-Month 022016 8,528 8,528 1,023 313 710
Total Contributions for the year [ 2015 ] 9,774 2,989 6,785
Total Transfer-Ins/VDRs for the year [ 2015 ] 0 0 0
Total Withdrawals for the year [ 2015 ] 0 0 0
Int. Updated upto 31/03/2016 403 123 0
Closing Balance as on 31/03/2016 10,177 3,112 6,785

----------------------fooj.k dh lekfIr/End Of Statement---------------------- eqfnzr/Printed On : 19-11-2024 13:07:19

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Disclaimer - Information shown above is based on available data on central server.This information may not be use for legal purpose.
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* Please never respond to any call for sharing any personal details like Aadhar, PAN, Bank details, OTP or request for any payment.
* EPFO never calls members/ pensioners to deposit any amount.
* Please do not make any payment based on any such call.
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