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)t
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 following
"Certified that the member mentioned at seriol No._____ Shri _____________ was dismissed for serious and willful misco
that the Employer's contribution for ____________ should be forfeited from the account in the fund. A copy of the order of
is enclosed."
"Certified that the member mentioned at seriol No._____ Shri _____________ was paid/not paid retrenchment compensat
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 Remarks
5 6 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.

For VARNICA HERBS

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 January 2008
Statutory rate of contribution for the month of January 2008

CODE NO
Particulars Wages on which Amount of Contribtion Amount of Contribution remitted Amount of
contributions are 3 4 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 0 0 0 0 0

PENSION FUND 0 NIL 0 NIL 0 NIL

A/C NO. 2&10

E.D.L.I. A/C NO.21&2 0 NIL 0 NIL 0 0

Total No of Employees
(a)Contract Name & Address of the STATE BANK OF INDIA,PON
(b)Rest Bank in which the amount
(c) Total 0 is remitted
Details 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
(To be filled by the EPFO)

Establishment status
Group Code

Amount of Date of remittence

adminitrative (enclose triplicate copies of
charges challan)
remitted
6 7

0 18 | 02 | 2 0 0 8 |

NIL 18 | 02 | 2 0 0 8 |

0 18 | 02 | 2 0 0 8 |

STATE BANK OF INDIA,PONDICHERRY

Signature of employer
with official(Seal)
Name and address of the Factory FORM NO. 5 CODE NO O
( The Employee's Provident Funds Scheme,1952[ Paragraph 36(2) (A) ] &
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 January 2008
(To be sent to the commissioner with form 2(EPF & EPS)

Father's name (or

husband's name in
Name of the employee ( In block case of married Date of
S.No Account No capitals ) woman) Birth
1 2 3 4 5
1
2
3
4
5
6
7

Place:

Date:

Stamp of Factory/Establishment
 CODE NO OF FACTORY/ESTABLISHMENT :

nth of January 2008

Total period of
previous service as on
Date of the date of joining the
joining the fund (Enclose scheme
Sex fund certificate if applicable) Remarks
6 7 8 9

Authorised Signatory