The Employees' Provident Fund Scheme, 1952 Form - 5

Paragarph 36 (2) (a) and (b)

Employees' Pension Scheme, 1995Paragarph 20 (4)

Return of Employees' qualifying for membership of the Employees' Provident Fund, Employees' Pension Scheme & Employees' Deposit Linked Insurance Fund for the firsttime during the month of

To be sent to the Commissioner with Form 2

Name & Address of the Factory/ Establishment :Code No. of Factory/ Establishment :

S. No Account No. Sex Remarks

123456789

101112131415

Signature of the employer or other authorised officer and stamp of the Factory / Establishment

Note: Please furnish details of the membership in remarks column if the employee was a member of Employees' Provident Fund and Employees' Family Pension schemebefore joining yourself/ factory. i.e. Account No. and/ or the name and particulars of the last employer.

Name of the Member (in BLOCK letters)

Father's Name or Husband's Name in case of married women

Age/ Date of Birth

Date of Eligibility for

Service

Total Period of Previous Service (excluding period of breaks) as on

the date of joining the Fund

Form - 5

Return of Employees' qualifying for membership of the Employees' Provident Fund, Employees' Pension Scheme & Employees' Deposit Linked Insurance Fund for the first

Remarks

Signature of the employer or other authorised officer and stamp of the Factory / Establishment

Please furnish details of the membership in remarks column if the employee was a member of Employees' Provident Fund and Employees' Family Pension scheme

The Employees' Provident Fund Scheme, 1952 Form - 10

Paragarph 36 (2) (a) and (b)

Employees' Pension Scheme, 1995Paragarph 20 (4)

Return of Members leaving service during the month of :Name & Address of the Factory/ Establishment :Code No. of Factory/ Establishment :

S. No Account No. Reason for Leaving Service Remarks

123456789

101112

Signature of the employer or other authorised officer and stamp of the Factory / Establishment

(1) A request for deduction from the account of a member dismissed for serious and willful misconduct should be reported by the following “certified that the member mentioned at Sr. No. Shri. was dismissed from the service for willful misconduct. I recommend that the employer's contribution for should be forfeited from his account in the fund. A copy of order of dismissal is enclosed.

(2) In case of discharge from service, the following certificate should be filled.Certified that the member mentioned in Sr. No. Shri. was paid/ unpaid retrenchment compensation of Rs.

Name of the Member (in BLOCK letters)

Father's Name or Husband's Name in case of married women

Date of Leaving Service

Please state whether the member is (a) retiring according to para 69 (1) (a) or (b) of the scheme; (b) leaving India for permanent settlement abroad; (c) retrenched; (d) ordinarily dismissed for serious and willful misconduct; (e) discharged; (f) resigning from or leaving service; (g) taking up employment elsewhere (the name and address of the new employer should be stated) ; (h) dead.

under the Industrial Disputes Act, 1947

Form - 10

Remarks

Signature of the employer or other authorised officer and stamp of the Factory / Establishment

(1) A request for deduction from the account of a member dismissed for serious and willful misconduct should be reported by the following “certified that the member

(2) In case of discharge from service, the following certificate should be filled.

Please state whether the member is (a) retiring according to para 69 (1) (a) or (b) of the scheme; (b) leaving India for permanent settlement abroad; (c) retrenched; (d) ordinarily dismissed for serious and willful misconduct; (e) discharged; (f) resigning from or leaving service; (g) taking up employment elsewhere (the name and address of the new

FORM 12-A (REVISED)

EMPLOYEES' PENSION SCHEME [PRARGRAPH 20(4)]Only for Un-Exempted Establishments

Name and address of the Establishment (To be filled in by EPFO)

Currency period from 1st April to 31st March Establishment Status

Statement of Contributions for the month of

Code No. Statutory Rate of Contribution % Group Code

Particulars Wages on whichAmount of Contribution

Amount Amount Date of Contributions of of Remittaceare Payable 3 4 Admin Admin (Enclose Triplicate

Recovered Payable by the Worker's Employer's Charges Charges Copies of Challan)from the Employer Share Share Due DueWorker

1 2 5 6

E.P.F. A/c No. 01

Pension Fund A/c No. 10 NIL NIL NIL NIL

D.L.I. A/c No. 21 NIL NIL

Total No. of Employees Name and address(a) Contract of the Bank in which(b) Rest amount is remitted:(c) Total

Details of Subscribers E.P.F.Pension

E.D.L.I.Scheme

THE EMPLOYEES' PROVIDENT FUNDS & MISC. PROVISION ACT, 1952

Amount of Contributions Remitted

Number as per last month's return

+) Number of Subscribers vide Form No. 5

-) Number of Subscribers vide Form No. 10

Net total Signature of Employer with Office Seal

COMBINED CHALLAN - A/C. NO. 1, 2, 10, 21 & 22 ORIGINAL

DUPLICATE

EMPLOYER'S PROVIDENT FUND ORGANIZATION TRIPLICATE

(USE SEPARATE CHALLANS FOR EACH MONTH) QUADRUPICATE

ESTABLISHMENT CODE NO.: ACCOUNT GROUP NO.: PAID BY CHEQUE/ CASH

M M Y Y Y YDUES FOR THE MONTH Employee Share D D M M Y Y Y YOF : DATE OF PAYMENT

Employer Share

Total No. of Subscribers:A/c 1 A/c 10 A/c 21

Total Wages Due:

S. NO. PARTICULARSA/C NO. 1 A/C NO. 2 A/C NO. 10 A/C NO. 21 A/C NO. 22 TOTAL

AMOUNT (in Rupees)

1 EMPLOYER'S SHARE OF CONTRIBUTION

2 EMPLOYEE'S SHARE OF CONTRIBUTION

3 ADMINISTRATIVE CHARGES

4 INSPECTION CHARGES

5 PENAL DAMAGES

6 MISCELLANEOUS PAYMENT

TOTAL 0.00 0.00 0.00 0.00 0.00 0.00

(Amount in words Rupees Only)NAME OF THE ESTABLISHMEN (For Bank use Only)ADDRESS Amount Received Rs.

For Cheques Only:NAME OF THE DEPOSITOR Date of Presentation:

Date of Realisation:SIGNAGURE OF THE DEPOSITOR Branch Name:

Branch Code No.

(TO BE FILLED IN BY EMPLOYER)

Name of the Bank : Cheque No. : Date :

The Employees' Provident Fund Scheme, 1952 Form - 3A

Paragarph 35 & 42

Employees' Pension Scheme, 1995Paragarph 19

Contribution card for currency period from 1st April to 31st March

1 Account No. 4 Name & Address of the Factory/ Establishment2 Name/ Surname

5 Statutory rate of contribution3 Father's/ Husband's Name 6 Voluntary higher rate of employee's contribution

if any

CONTRIBUTIONS

Month

Worker's Share Employer's Share

RemarksEPF Total From To

1 2 3 4a 4b 4c 5 6a 6b 7AprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberJanuaryFebruaryMarchOtherTotal 0.00 0.00 0.00 0.00 0.00 0.00

(a) Date of Leaving Service (b) Reason for leaving service

Certified that the total amount of contribution (both shares) indicated in this card i.e. Rs. Onlyhas already been remitted in full in EPF A/c No. 1 and Pension Fund A/c No. 10

Refund of Wages

Period of non contributing service

Amount of Wages

EPF Difference between 12% &

10% (if any)

Pension Fund (EPS) Contribution 8-1/3%

Certified that the total difference between the total of the contributin shown under col (3) and (4) of the table of reverse and that arrived at on the total wages shown in col (2) at the prescribed rate is solely due to the rounding off contribution to the nearest rupees under the rules.

Certified that the difference between the total of the contribution shown under cols. 3, 4a and 4b of the above table and that arrived at on the total wages shown in col. 2 at the prescribed rate is solely due to rounding off of contribution to the nearest rupee under the rules.

Signature of the employer or other authorised officer and stamp of the Factory / Establishment

The Employees' Provident Fund Scheme, 1952 Form - 6A

Paragarph 43

Employees' Pension Scheme, 1995

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

Statutory rate of contribution 12.00 %

No. of members voluntarily contributing at a higher rate:Code No. of Establishment

Account No. Total Remarks

1 2 3 4 5 6 7 8 9 10

Grand Total Rs. 0.00 0.00 0.00 0.00 0.00

Name & Address of the Establishment

Sr. No.

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%

Pension Fund 8-1/3%

Refund of Advance

Rate of higher

voluntary contribution

(if any)