E.S.I.C. E.S.I.C.

Challan No. Challan No.

EMPLOYEES' STATE INSURANCE FUND ACCOUNT NO.-1 EMPLOYEES' STATE INSURANCE FUND ACCOUNT NO.-1
PAY-IN-SLIP FOR CONTRIBUTION STATE BANK OF INDIA PAY-IN-SLIP FOR CONTRIBUTION STATE BANK OF INDIA

Station Dated Station Dated

Paid into credit of the Employee's State Paid into credit of the Employee's State
Particulars of Amount Particulars of Amount
Insurance Fund. Insurance Fund.
Cash/Cheque No. Cash/Cheque No.
Rs. Ps. Account No. 1 Rs. 0.00 Rs. Ps. Account No. 1 Rs. 0.00
0.0 Rupees Forty Five Thousand Seven 0 0.0 Rupees Forty Five Thousand Seven
Hundred Seventy two Only. Hundred Seventy two Only.

In Cash/by Cheque (on realisation) for payment In Cash/by Cheque (on realisation) for payment
of contribution as per details given of contribution as per details given
below under the Employees State Insurance below under the Employees State Insurance
Total 0 0.0 Act, 1948. For the Month of Total 0 0.0 Act, 1948. For the Month of

Employer's Code No. 35-131-111 Deposited by Employer's Code No. Deposited by

Name and Address of Name and Address of

Factory/Establishment Factory/Establishment
0

No. of Employees No. of Employees 0

Total Wages Total Wages 0.00

Employees' Contribution Rs. Employees' Contribution Rs. 0.00

Employers' Contribution Rs Employers' Contribution Rs 0.00
0
Total Contribution Rs. 0.00 Total Contribution Rs. 0.00

(For use in Bank) (For use in Bank)

ACKNOWLEDGEMENT ACKNOWLEDGEMENT
Received payment with Cast/Cheque/Draft No.
Dated for Rs. 0.00 Dated for Rs. 0.00
In Word Rs In Word Rs

Drawn on Bank in favour of Drawn on Bank in favour of

Employees State Insurance Fund Account No. 1 Employees State Insurance Fund Account No. 1
Sl. No. in Bank's Scroll Sl. No. in Bank's Scroll
Authorised Signatory Authorised Signatory