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Name and address of the Factory

M/s.

The Employee's Provident Fund Scheme, 1952 [Paragraph

Return of the members leaving service during the month of January 2008

SL

NO.

1 2 3 4

1

2

3

4

5

Place:

Date:

Stamp of establishment

Please state whether the member is (a) retiring according to para 69(1) (a) (b) of the scheme

retrenchment(d)ordinarily dismissed for serious an willful misconduct (e) discharge(f)resigni

elsewhere. (The name and address of the employers should be stated)(h) Death.

A request for deduction from the account of the member dismissed for serious and willful misconduct s

"Certified that the member mentioned at seriol No._____ Shri _____________ was dismissed

that the Employer's contribution for ____________ should be forfeited from the account in the

is enclosed."

"Certified that the member mentioned at seriol No._____ Shri _____________ was paid/not p

under the Industrial Dispute Act 1947."

Also fill in form no. 5 overleaf

FORM NO. 10

Employee,s Pension Scheme,1995[paragraph 20(2)]

Account No

Name of member ( In block

letters)

Father's Name (or

husband's name in case of

married woman)

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CODE NO OF FACTORY/ESTABLISHMENT:

36(2)(A) &(B)]

5 6 7

Authorized Signatory

(b) leaving India for permanent settlement abroad

g from or leaving service(g)taking up employment

ould be reserted by the following certificate

for serious and willful misconduct. I recommend

fund. A copy of the order of dismissed

aid retrenchment compensation of Rs.

Authorized Signatory

Date of leaving

service

Reason for

leaving

service Remarks

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Only for un-exempted establishment FORM 12-A (REVISED) (To be fille

EMPLOYEES' PROVIDENT FUND AND MISC PROVISIONS ACT 1952

Employees' Pension Scheme (Paragraph 20(4)}

Name and address of the EstablishmentCURRENCY PERIOD FROM IST APRIL 2007 TO 31ST MARCH-2008

Statutory rate of contribution for the month of

CODE NO

Particulars Wages on which Amount of Contribtion Amount of Contribution remitted Amount of

contributions are adminitrative

payable Recovered from Payable by Worker's share Employer's Share charges

the workers the employer due

1 2 5

E.P.F. A/C NO. 01

PENSION FUND Nil Nil Nil

A/C NO. 2&10

E.D.L.I. A/C NO.21&22 Nil Nil

Total No of Employees

(a)Contract Name & Address of the

(b)Rest Bank in which the amount

(c) Total 0 is remittedDetails of Subscribers E.P.F. Pension Fund EDLI

No.of Subscribers as perlast month 0 0

No.of New Subscribers (Vide Form5) 0 0

No.of Subscribers left service (Vide Form 10) 0 0

(Nett) Total Number of Subscribers 0 0 0

Statement of contribution for the month of

3 4

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by the EPFO)

Establishment status

Group Code

Amount of Date of remittence

adminitrative (enclose triplicate copies of

charges challan)

remitted

6 7

Nil

0

Signature of employer

with official(Seal)

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Statutory rate of contri

Sr.

No.

1

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Paragarph 43

Employees' Pension Scheme, 19

Annual statement of contribution for the currency period 1st April to 31st March

The Employees' Provident Fund Sche

No. of members volun

Code No. of Establishment

Name & Address of the

Establishment

Account No.

TN/VL/74611

Name of the Member

(in BLOCK letters)

Wages retaining

allowances (if any)

& DA including cash

value of food

concession paid

during the currency

period.

Amount of

Workers

contribution

deducted

from the

wages

EPF between

10% &

8-1/3%

Pen

Fu

8-1/

2 3 4 5 6

Grand Total Rs. 0.00 0.00 0.00

Mar-08

A/c.No. 2 A/c.No. 21 A/c.No. 22Month Wages A/c.No. 1 A/c.No. 10

Jul-08

Jun-08

May-08

Apr-08

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Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.

Rs. Rs. Rs. Rs. Rs. Rs.Rs. Rs. Rs. Rs. Rs. Rs.

NOTE:- (1) The names of all members, including those who had left service during the currency period, should b

(2) In case of substantial variation in the wages/contribution of any members as compared to those shown in pre

(3) In respect of those members who have not opted for Pension Fund entire employers contribution @ 81/3 % o

Sep-08

Aug-08

TotalFeb-09

Jan-09

Dec-08

Nov-08

Oct-08

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bution

Rs.

Rs.

Rs.

Rs.

Rs.

Form - 6A

95

e, 1952

arily contributing at a higher rate:

ion

nd

3%

TotalRefund of

Advance

Rate of

higher

voluntary

contribution

(if any)

Remarks

8 9 10

0.00 0.00

Total

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Rs.

Rs.

Rs.

Rs.

Rs.

Rs.

Rs.Rs.

Signature of Employer(with office seal)

included in this statement. Where the Form3-A in respect of such members had left service, the fact should

ious months statement. The reason should be explained adequately in the 'Remarks' column.

r 10% as the case may be shown under column No.6.

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be stated against the members in the 'Remarks' column.

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Name and address of the Factory

The Employees' Pension Scheme,1995 [Paragraph 20 (4) ] )

Details of Employees qualifyind for membership of the fund for the first time during the month of Janu

(To be sent to the commissioner with form 2(EPF & EPS)

1 2 3 4 5

1

2

34

5

6

7

Place:

Date:

Stamp of Factory/Establishment

FORM NO. 5

( The Employee's Provident Funds Scheme,1952[ Paragraph 36(2) (A) ] &

Date of

BirthS.No Account No

Name of the employee ( In block

capitals )

Father's name (or

husband's name in

case of married

woman)

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ry 2008

6 7 9

Authorised Signatory

8

CODE NO OF FACTORY/ESTABLISHMENT :

Sex

Date of

joining the

fund

Total period of

previous service as on

the date of joining the

fund (Enclose scheme

certificate if applicable) Remarks