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EMPLOYEES STATE INSURANCE CORPORATION

ORIGINAL
For Bank

Challan Form for Deposit in A/c No. 1


Employers Code 5175787101
Region code
5

Employer code
7

Industry
Code
7

Date

Month

Year

Bank & Branch Code*

Name of
Factory /
Estt. &
Address

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,


2A&B, III FLOOR, RAJA ANNAMALAI BUILDING,
NO.19,MARSHALLS ROAD, CHENNAI - 08.

Mode of Payment [Tick ()]


Cash

Cheque/D.D.No.
Dated:
Drawn on (Name of the Bank/Branch)
TAMILNAD MERCANTILE BANK LTD TTK ROAD, CHENNAI.

Cheque
D.D.
Period of contribution

Month - SEPTEMBER

Regular Contribution

Nature of Payment [Tick ()]


Total Wages : Rs.

Year - 2011

Interest
Others

Damages

No. of Employees: 7

Rs.

Ps.

Employees Contribution
1 2 2 5
0 0
Employers contribution
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
Total amount (in words) (Four Thousand Five Hundred and Seventy Seven Only)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________

Bank
Seal

______________________________________
Signature

______________________________________
Name & Designation Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________
Received Rs.4577.00
(Rs. Four Thousand Five Hundred and Seventy Seven only)
In Cash /by Cheque/DD No. .. Dated.. Subject to
Realisation) Drawn on .... (Bank) in favour of ESIC A/c No.1

* (For Bank Branch Code see on reverse)

For use in Bank


Bank Scroll No. .
Date: .
Authorised signature & Seal of the Receiving
Bank

Important: Affix Correct Code No. Name Seal


and Period of contribution to avoid missing credit

EMPLOYEES STATE INSURANCE CORPORATION

DUPLICATE
For ESIC through Bank

Challan Form for Deposit in A/c No. 1


Employers Code 5175787101
Region code
5

Employer code
7

Industry
Code
7

Date

Month

Year

Bank & Branch Code*

Name of
Factory /
Estt. &
Address

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,


2A&B, III FLOOR, RAJA ANNAMALAI BUILDING,
NO.19,MARSHALLS ROAD, CHENNAI - 08.

Mode of Payment [Tick ()]


Cash

Cheque/D.D.No.
Dated:
Drawn on (Name of the Bank/Branch)
TAMILNAD MERCANTILE BANK LTD TTK ROAD, CHENNAI.

Cheque
D.D.
Period of contribution

Month - SEPTEMBER

Regular Contribution

Nature of Payment [Tick ()]


Total Wages : Rs.

Year - 2011

Interest
Others

Damages

No. of Employees: 7

Rs.

Ps.

Employees Contribution
1 2 2 5
0 0
Employers contribution
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
Total amount (in words) (Four Thousand Five Hundred and Seventy Seven Only)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________

Bank
Seal

______________________________________
Signature

______________________________________
Name & Designation Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________
Received Rs.4577.00
(Rs. Four Thousand Five Hundred and Seventy Seven only)
In Cash /by Cheque/DD No. .. Dated.. Subject to
Realisation) Drawn on .... (Bank) in favour of ESIC A/c No.1

* (For Bank Branch Code see on reverse)

For use in Bank


Bank Scroll No. .
Date: .
Authorised signature & Seal of the Receiving
Bank

Important: Affix Correct Code No. Name Seal


and Period of contribution to avoid missing credit

EMPLOYEES STATE INSURANCE CORPORATION

TRIPLICATE
For Depositor

Challan Form for Deposit in A/c No. 1


Employers Code 5175787101
Region code
5

Employer code
7

Industry
Code
7

Date

Month

Year

Bank & Branch Code*

Name of
Factory /
Estt. &
Address

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,


2A&B, III FLOOR, RAJA ANNAMALAI BUILDING,
NO.19,MARSHALLS ROAD, CHENNAI - 08.

Mode of Payment [Tick ()]


Cash

Cheque/D.D.No.
Dated:
Drawn on (Name of the Bank/Branch)
TAMILNAD MERCANTILE BANK LTD TTK ROAD, CHENNAI.

Cheque
D.D.
Period of contribution

Month - SEPTEMBER

Regular Contribution

Nature of Payment [Tick ()]


Total Wages : Rs.

Year - 2011

Interest
Others

Damages

No. of Employees: 7

Rs.

Ps.

Employees Contribution
1 2 2 5
0 0
Employers contribution
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
Total amount (in words) (Four Thousand Five Hundred and Seventy Seven Only)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________

Bank
Seal

______________________________________
Signature

______________________________________
Name & Designation Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________
Received Rs.4577.00
(Rs. Four Thousand Five Hundred and Seventy Seven only)
In Cash /by Cheque/DD No. .. Dated.. Subject to
Realisation) Drawn on .... (Bank) in favour of ESIC A/c No.1

* (For Bank Branch Code see on reverse)

For use in Bank


Bank Scroll No. .
Date: .
Authorised signature & Seal of the Receiving
Bank

Important: Affix Correct Code No. Name Seal


and Period of contribution to avoid missing credit

EMPLOYEES STATE INSURANCE CORPORATION

QUADRUPLICATE
For Depositor to be attached
with Return of contributions

Challan Form for Deposit in A/c No. 1


Employers Code 5175787101
Region code
5

Employer code
7

Industry
Code
7

Date

Month

Year

Bank & Branch Code*

Name of
Factory /
Estt. &
Address

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,


2A&B, III FLOOR, RAJA ANNAMALAI BUILDING,
NO.19,MARSHALLS ROAD, CHENNAI - 08.

Mode of Payment [Tick ()]


Cash

Cheque/D.D.No.
Dated:
Drawn on (Name of the Bank/Branch)
TAMILNAD MERCANTILE BANK LTD TTK ROAD, CHENNAI.

Cheque
D.D.
Period of contribution

Month - SEPTEMBER

Regular Contribution

Nature of Payment [Tick ()]


Total Wages : Rs.

Year - 2011

Interest
Others

Damages

No. of Employees: 7

Rs.

Ps.

Employees Contribution
1 2 2 5
0 0
Employers contribution
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
Total amount (in words) (Four Thousand Five Hundred and Seventy Seven Only)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________

Bank
Seal

______________________________________
Signature

______________________________________
Name & Designation Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________
Received Rs.4577.00
(Rs. Four Thousand Five Hundred and Seventy Seven only)
In Cash /by Cheque/DD No. .. Dated.. Subject to
Realisation) Drawn on .... (Bank) in favour of ESIC A/c No.1

* (For Bank Branch Code see on reverse)

For use in Bank


Bank Scroll No. .
Date: .
Authorised signature & Seal of the Receiving
Bank

Important: Affix Correct Code No. Name Seal


and Period of contribution to avoid missing credit