FORM - 3A

(Unexempted Establishment Only)

THE EMPLOYEE'S PROVIDENT FUND SCHEME, 1952
(Paras 35 and 42) and
THE EMPLOYEES PENSION SCHEME, 1995
Para 20
Contribution Card for the currency period from April to March 31
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1. Account No. 5. Statutoty Rate of Contribution :
2. Name/Surname 6. Voluntary higher rate of Employees
3. Father/Husband's Name contribution, if any
4. Name & Address of the Establishment : 7. Whether opted to contribute on full salary
for pension? Yes/No

Month Amount of CONTRIBUTIONS Refund Non cont. Remarks

Wages Worker's Share Employer Share of services
Rs. Advances from
EPF EPF EPS TOTAL ---------To---
a b c ------

1 2 3 4 5 6 7
a) Date of Leaving service
April 200
May 200
June 200 b) Reason for leaving service
July 200
August 200 c) Certified that the total amount of
September 200 contribution indicated in this card

October 200 i.e. Rs. 0.00

November 200
December 200 Col 3+Col4 ( c ) has already been
January 200 remitted in full in EPF A/c No 1
February 200 ( Provident Fund contribution A/c)
and in A/c no. 10 ( Pension
March 200 Fund Contribution account vide
note below )
0 0 0 0 0

Certified That the difference between the total of the contribution shown under the columns (3) & (4)
of the above table and that arrived at on the total Wages shown in Column (2) at the Prescribed rate
is solely due to the rounding off of the contributions to the nearest rupee under the rule.
*Contribution for the month of March paid in April

*IN THE CASE OF AN EMPLOYEE WHO HAS LEFT THE SERVICE OF THE COMPANY EARLIER, HIS CONTRIBUTION
HAS BEEN SHOWN IN THE SUBSEQUENT MONTH WHICH HIS FINAL SETTLEMENT OF SALARY HAS BEEN MADE.

Signature of Employer
Date : (Office Seal)

Note: 1 ) In respect of the Form (3A) sent to the Regional office during the course of the currency
period for the purpose of final settlement of the accounts of the members who had left service
details of date and reasons for leaving service and also certificate as shown in the Remarks
Column should be added.
Note: 2 ) If there is no period of NCS, the word "NIL" to be mentioned against the total column.
Note: 3 ) Wherever no wages are shown against any month the period should be shown as NCS
Under Col. 6.