The Employees' Provident Fund Scheme, 1952 Form - 5

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

Employees' Pension Scheme, 1995
Paragarph 20 (4)

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

To be sent to the Commissioner with Form 2

Name & Address of the Factory/ Establishment :

Code No. of Factory/ Establishment :

Total Period of
Previous Service
Date of
Name of the Member Father's Name or Husband's Age/ Date of (excluding period
S. No Account No. Sex Eligibility for Remarks
(in BLOCK letters) Name in case of married women Birth of breaks) as on the
Service
date of joining the
Fund
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

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 scheme
before joining yourself/ factory. i.e. Account No. and/ or the name and particulars of the last employer.
 Form - 5

r the first

emarks

lishment

scheme
 The Employees' Provident Fund Scheme, 1952 Form - 10
Paragarph 36 (2) (a) and (b)
Employees' Pension Scheme, 1995
Paragarph 20 (4)

Return of Members leaving service during the month of :

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

Name of the Member Father's Name or Husband's Date of Leaving

S. No Account No. Reason for Leaving Service Remarks
(in BLOCK letters) Name in case of married women Service

1
2
3
4
5
6
7
8
9
10
11
12

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

(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.
under the Industrial Disputes Act, 1947
 Form - 10

emarks

lishment
(d) ordinarily
e new

er
 FORM 12-A (REVISED)

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

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 which Amount of Contributions Amount Amount Date of

Amount of Contribution
Contributions Remitted of of Remittace
are 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 Due
Worker
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

Pension
Details of Subscribers E.P.F. E.D.L.I.
Scheme
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 Y
DUES FOR THE MONTH Employee Share D D M M Y Y Y Y
OF : DATE OF PAYMENT
Employer Share

Total No. of Subscribers:

A/c 1 A/c 10 A/c 21
Total Wages Due:

A/C NO. 1 A/C NO. 2 A/C NO. 10 A/C NO. 21 A/C NO. 22 TOTAL
S. NO. PARTICULARS
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 ESTABLISHMENT (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 :

CATE

nly)
 The Employees' Provident Fund Scheme, 1952 Form - 3A
Paragarph 35 & 42
Employees' Pension Scheme, 1995
Paragarph 19

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

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

2 Name/ Surname
5 Statutory rate of contribution
3 Father's/ Husband's Name 6 Voluntary higher rate of employee's contribution
if any

CONTRIBUTIONS
Period of non contributing
Worker's Share Employer's Share
service
EPF Difference Refund of
Month Amount of Pension Fund (EPS) Remarks
EPF between 12% & 10% Total Wages From To
Wages Contribution 8-1/3%
(if any)
1 2 3 4a 4b 4c 5 6a 6b 7
April
May
June
July
August
September
October
November
December
January
February
March
Other
Total 0.00 0.00 0.00 0.00 0.00 0.00

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.
(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.
has already been remitted in full in EPF A/c No. 1 and Pension Fund A/c No. 10

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
 Form - 3A

emarks

in col (2) at

Only

ol. 2 at the
lishment
 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

Name & Address of the Statutory rate of contribution 12.00 %

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

Wages retaining
Amount of
allowances (if any) & Rate of
Workers
DA including cash EPF between Pension higher
Sr. Name of the Member contribution Refund of
Account No. value of food 10% & Fund Total voluntary Remarks
No. (in BLOCK letters) deducted Advance
concession paid 8-1/3% 8-1/3% contribution
from the
during the currency (if any)
wages
period.

1 2 3 4 5 6 7 8 9 10

Grand Total Rs. 0.00 0.00 0.00 0.00 0.00

Form - 6A

Remarks

10