Name and address of the Factory M/s.

FORM NO. 10 The Employee's Provident Fund Scheme, 1952 [Paragraph 36(2)(A) &(B)] Employee,s Pension Scheme,1995[paragraph 20(2)] Return of the members leaving service during the month of January 2008 SL NO. Father's Name (or Name of member ( In block husband's name in case of Account No letters) married woman) 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 (b) leaving India for permane retrenchment(d)ordinarily dismissed for serious an willful misconduct (e) discharge(f)resigning from or leaving service(g)ta 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 should be reserted by the followin

"Certified that the member mentioned at seriol No._____ Shri _____________ was dismissed for serious and willful miscon that the Employer's contribution for ____________ should be forfeited from the account in the fund. A copy of the order of d is enclosed." "Certified that the member mentioned at seriol No._____ Shri _____________ was paid/not paid retrenchment compensati under the Industrial Dispute Act 1947." Also fill in form no. 5 overleaf

CODE NO OF FACTORY/ESTABLISHMENT:

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

Reason for Date of leaving leaving service service 5 6

Remarks 7

Authorized Signatory the scheme (b) leaving India for permanent settlement abroad rge(f)resigning from or leaving service(g)taking up employment
misconduct should be reserted by the following certificate

as dismissed for serious and willful misconduct. I recommend ccount in the fund. A copy of the order of dismissed

as paid/not paid retrenchment compensation of Rs.

Authorized Signatory

Only for un-exempted establishment

FORM 12-A (REVISED) (To be filled by the EPFO EMPLOYEES' PROVIDENT FUND AND MISC PROVISIONS ACT 1952 Employees' Pension Scheme (Paragraph 20(4)} Name and address of the Establishment
CURRENCY PERIOD FROM IST APRIL 2007 TO 31ST MARCH-2008

Statement of contribution for the month of Statutory rate of contribution for the month of

CODE NO
Particulars Wages on which contributions are payable the workers Amount of Contribtion 3 Recovered from Payable by the employer Worker's share Amount of Contribution remitted 4 Employer's Share Amount of adminitrative charges due

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

PENSION FUND A/C NO. 2&10

Nil

Nil

Nil

E.D.L.I. A/C NO.21&22 Nil Total No of Employees (a)Contract (b)Rest (c) Total 0 Details of Subscribers No.of Subscribers as perlast month No.of New Subscribers (Vide Form5) No.of Subscribers left service (Vide Form 10) (Nett) Total Number of Subscribers

Nil Name & Address of the Bank in which the amount is remitted E.P.F. Pension Fund 0 0 0 0 0

EDLI 0 0 0 0

(To be filled by the EPFO)

Establishment status Group Code

Amount of charges remitted

Date of remittence challan)

adminitrative (enclose triplicate copies of

Nil

Signature of employer with official(Seal)

The Employees' Provident Fund Scheme, 1952

Paragarph 43

Employees' Pension Scheme, 1995

Annual statement of contribution for the currency period 1st April Name & Address of the Establishment Code No. of Establishment Wages retaining Amount of allowances (if any) Workers & DA including cash EPF between contribution value of food 10% & deducted concession paid 8-1/3% from the during the currency wages period. 4 5 6 to 31st March Statutory rate of contribution

No. of members voluntarily contribut

Sr. No.

Account No. TN/VL/74611

Name of the Member (in BLOCK letters)

Pension Fund 8-1/3%

1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Grand Total Rs.

0.00

0.00

0.00

0.00

Month Mar-08 Apr-08 May-08 Jun-08 Jul-08

Wages Rs. Rs. Rs. Rs. Rs.

A/c.No. 1 Rs. Rs. Rs. Rs. Rs.

A/c.No. 10 Rs. Rs. Rs. Rs. Rs.

A/c.No. 2 Rs. Rs. Rs. Rs. Rs.

A/c.No. 21 Rs. Rs. Rs. Rs. Rs.

A/c.No. 22 Rs. Rs. Rs. Rs. Rs.

Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Total

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 be included in th (2) In case of substantial variation in the wages/contribution of any members as compared to those shown in previous months s (3) In respect of those members who have not opted for Pension Fund entire employers contribution @ 81/3 % or 10% as the c

und Scheme, 1952

Form - 6A

cheme, 1995

rate of contribution

embers voluntarily contributing at a higher rate:

Pension Fund 8-1/3%

Total

Refund of Advance

Rate of higher voluntary

contribution

Remarks

(if any) 7 8 9 10

0.00

0.00

Total Rs. Rs. Rs. Rs. Rs.

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

Signature of Employer(with office seal)

od, should be included in this statement. Where the Form3-A in respect of such members had left service, the fact should be stated against shown in previous months statement. The reason should be explained adequately in the 'Remarks' column. n @ 81/3 % or 10% as the case may be shown under column No.6.

e fact should be stated against the members in the 'Remarks' column.

Name and address of the Factory

FORM NO. 5
( The Employee's Provident Funds Scheme,1952[ Paragraph 36(2) (A) ] & The Employees' Pension Scheme,1995 [Paragraph 20 (4) ] )

CODE NO O

Details of Employees qualifyind for membership of the fund for the first time during the month of January 2008 (To be sent to the commissioner with form 2(EPF & EPS)

S.No Account No 1 2 1 2 3 4 5 6 7

Name of the employee ( In block capitals ) 3

Father's name (or husband's name in case of married woman) 4

Date of Birth 5

Place: Date: Stamp of Factory/Establishment

CODE NO OF FACTORY/ESTABLISHMENT :

nth of January 2008

Sex 6

Date of joining the fund 7

Total period of previous service as on the date of joining the fund (Enclose scheme certificate if applicable) Remarks 8 9

Authorised Signatory