Declaration Form to be submitted alongwith application Form 31 for purchase of a
dwelling site/house/flat or re-construction of dwelling house, or for
addition/alteration of the dwelling house

1 Name of the E.P.F. Member
2 Father I Husband's Name
3 Employees' Provident Fund Ale
No.
4 Permanent Address
5 Complete Address of the
dwelling site I dwelling house or
flat or house under construction
for which withdrawal is applied
for.
- Name & address of the
owner of plot/house from
whom
purchased I agreement
executed.
- Survey no. I plot
no./khatta
no./Registration number
and the year of the title
deed
- Boundary
- East
- West
- South
- North
- Area of Site and/house
6 Name of authaority who
approved site plan with reference
no. and date.
7 Whether copy of agreement for
purchase I allotment letter, in case
of purchase is enclosed.
8 Estimate of value of
property/house/flat or estimated
cost of
construction/addition/alteration
9 Whether withdrawal for housing
was availed previously, if so the
amount, date of sanction.

purpose etc.
10 Permission /license no. for
construction issued by local
authority with name of local

I body in the area of construction.
DECLARATION & UNDERTAKJNG
(I) I ....................................... S/o, D/o, W/o ............................. do hereby solemnly declare that the information furnished above are true to the best of my knowledge and the above mentioned "(Dwelling site of Dwelling House/flat or hou.se under construction) is free from all encumberances. I also declare that I am not purchasing~ share in joint property or constructing a house on a site owned jointly except with the spouse. I undertake that the house/site/flat is registered/will be registered in my name/my spouse
(name) ........................... (give name of wife/husband)or jointly in the name of my
spouse ............................ (give name and myself.
(II) I hereby undertake to submit a copy of Regd. deed/allotment possession memo/ construction/completion certificate Immediately on receipt/completion within one year whichever is earlier.
(Ill) I also undertake to produce the above documents whenever demanded by the sanctioning authority for future verification.
(IV) I understand that as per the provision of Employees' Provident Fund Scheme, 19 2, I am liable to refund the entire amount of withdrawal in lump sum with penal interest in case the amount is used for any purpose other than the purpose stated in the application. I authorize the Regional Provident Fund Commissioner to recover the amount sanctioned with penal interest @ 2% p.a. from my wages in case I failed to produce copy of Regd. purchase deed/completion certificate within six months/twelve months after the withdrawal of the amount as the case may be.
Sign. of EPF member (with name thereunder)
Present Address ........................................... .
Counter Signed.
Establishment Seal & Date
I certify that I have verified the above particulars and have read. out the contents of the declaration of Sh./Smt. ........................ . and he/she has signed /thumb impression before me.
Name & Designation of the Employer.
Strick out in-applicable words/phrases/