COMBINED CHALLAN OF A/C NO.

1,2,10,21 & 22 (USE SEPARATE CHALLAN FOR EACH MONTH)

(STATE BANK OF INDIA) QUARDUPLICATE
EMPLOYEES' PROVIDENT FUND ORGANISATION
ESTABLISHMENT CODE ACCOUNT GROUP NO. PAID BY CHEQUE /CASH
M M Y Y Y Y D D M M Y Y
EMPLOYEES'SHARE 1 | 1 2|0|0 |4 | 1 | 2 | 0 |4

DUE FOR THE MONTH OF

EMPLOYER'S SHARE 1 | 1 2|0|0 |4

TOTAL NO. OF SUBSCRIBERS 0 0

A/C NO. I A/c no.10 A/c No. 21
TOTAL WAGES DUE 0 0

A/C NO.1 A/C NO.2 A/C NO. 10 A/C NO. 21 A/C NO. 22
S.NO. PARTICULARS AMOUNT (IN RUPEES) TOTAL

1 EMPLOYERS'S SHARE OF CONT. 0

2 EMPLOYEES'S SHARE OF CONT. 0
3 ADMN. CHARGES 0
4 INSP CHARGES
5 PENDAL DAMAGES
6 MISC PAYMENTS (PAST
ACCUMULATIONS ONLY)
TOTAL 0 0 0 0 0

(AMOUNT IN WORDS

NAME OF THE ESTT. FOR BANK USE ONLY)

ADDRESS AMOUNT RECEIVED RS.
FOR CHEQUES ONLY
DATE OF REALISATION
NAME OF THE DEPOSITOR BRANCH NAME
SIGNATURE OF THE DEPOSITOR BRANCH CODE NO.
(TO BE FILLED IN BY EMPLOYER)
NAME OF THE BANK CHEQUE NO DATE
COMBINED CHALLAN OF A/C NO. 1,2,10,21 & 22 (USE SEPARATE CHALLAN FOR EACH MONTH)
(STATE BANK OF INDIA) TRIPLICATE
EMPLOYEES' PROVIDENT FUND ORGANISATION
ESTABLISHMENT CODE 0 ACCOUNT GROUP NO. PAID BY CHEQUE /CASH
M M Y Y Y Y D D M M Y Y
EMPLOYEES'SHARE 1 | 1 2|0|0 |4 | 1 | 2 | 0 |4

DUE FOR THE MONTH OF

EMPLOYER'S SHARE 1 | 1 2|0|0 |4

TOTAL NO. OF SUBSCRIBERS 0 0 0

A/C NO. I A/c no.10 A/c No. 21
TOTAL WAGES DUE 0 0 0

A/C NO.1 A/C NO.2 A/C NO. 10 A/C NO. 21 A/C NO. 22
S.NO. PARTICULARS AMOUNT (IN RUPEES) TOTAL

1 EMPLOYERS'S SHARE OF CONT. 0 0 0 0

2 EMPLOYEES'S SHARE OF CONT. 0 0
3 ADMN. CHARGES 0 0 0
4 INSP CHARGES
5 PENDAL DAMAGES
6 MISC PAYMENTS (PAST
ACCUMULATIONS ONLY)
TOTAL 0 0 0 0 0 0

(AMOUNT IN WORDS 0

NAME OF THE ESTT. 0 FOR BANK USE ONLY)

ADDRESS 0 AMOUNT RECEIVED RS.
FOR CHEQUES ONLY
DATE OF REALISATION
NAME OF THE DEPOSITOR BRANCH NAME
SIGNATURE OF THE DEPOSITOR BRANCH CODE NO.
 (TO BE FILLED IN BY EMPLOYER)
NAME OF THE BANK CHEQUE NO DATE
COMBINED CHALLAN OF A/C NO. 1,2,10,21 & 22 (USE SEPARATE CHALLAN FOR EACH MONTH)
(STATE BANK OF INDIA) DUPLICATE
EMPLOYEES' PROVIDENT FUND ORGANISATION
ESTABLISHMENT CODE 0 ACCOUNT GROUP NO. PAID BY CHEQUE /CASH
M M Y Y Y Y D D M M Y Y
EMPLOYEES'SHARE 1 | 1 2|0|0 |4 | 1 | 2 | 0 |4

DUE FOR THE MONTH OF

EMPLOYER'S SHARE 1 | 1 2|0|0 |4

TOTAL NO. OF SUBSCRIBERS 0 0 0

A/C NO. I A/c no.10 A/c No. 21
TOTAL WAGES DUE 0 0 0

A/C NO.1 A/C NO.2 A/C NO. 10 A/C NO. 21 A/C NO. 22
S.NO. PARTICULARS AMOUNT (IN RUPEES) TOTAL

1 EMPLOYERS'S SHARE OF CONT. 0 0 0 0

2 EMPLOYEES'S SHARE OF CONT. 0 0
3 ADMN. CHARGES 0 0 0
4 INSP CHARGES
5 PENDAL DAMAGES
6 MISC PAYMENTS (PAST
ACCUMULATIONS ONLY)
TOTAL 0 0 0 0 0 0

(AMOUNT IN WORDS 0

NAME OF THE ESTT. 0 FOR BANK USE ONLY)

ADDRESS 0 AMOUNT RECEIVED RS.
FOR CHEQUES ONLY
DATE OF REALISATION
NAME OF THE DEPOSITOR BRANCH NAME
SIGNATURE OF THE DEPOSITOR BRANCH CODE NO.
(TO BE FILLED IN BY EMPLOYER)
NAME OF THE BANK CHEQUE NO DATE
COMBINED CHALLAN OF A/C NO. 1,2,10,21 & 22 (USE SEPARATE CHALLAN FOR EACH MONTH)
(STATE BANK OF INDIA) ORIGINAL
EMPLOYEES' PROVIDENT FUND ORGANISATION
ESTABLISHMENT CODE 0 ACCOUNT GROUP NO. PAID BY CHEQUE /CASH
M M Y Y Y Y D D M M Y Y
EMPLOYEES'SHARE 1 | 1 2|0|0 |4 | 1 | 2 | 0 |4

DUE FOR THE MONTH OF

EMPLOYER'S SHARE 1 | 1 2|0|0 |4

TOTAL NO. OF SUBSCRIBERS 0 0 0

A/C NO. I A/c no.10 A/c No. 21
TOTAL WAGES DUE 0 0 0

A/C NO.1 A/C NO.2 A/C NO. 10 A/C NO. 21 A/C NO. 22
S.NO. PARTICULARS AMOUNT (IN RUPEES) TOTAL

1 EMPLOYERS'S SHARE OF CONT. 0 0 0 0

2 EMPLOYEES'S SHARE OF CONT. 0 0
3 ADMN. CHARGES 0 0 0
4 INSP CHARGES
5 PENDAL DAMAGES
6 MISC PAYMENTS (PAST
ACCUMULATIONS ONLY)
TOTAL 0 0 0 0 0 0

(AMOUNT IN WORDS 0

NAME OF THE ESTT. 0 FOR BANK USE ONLY)

ADDRESS 0 AMOUNT RECEIVED RS.
FOR CHEQUES ONLY
DATE OF REALISATION
NAME OF THE DEPOSITOR BRANCH NAME
SIGNATURE OF THE DEPOSITOR BRANCH CODE NO.
(TO BE FILLED IN BY EMPLOYER)
NAME OF THE BANK CHEQUE NO DATE
Only for un-exempted establishment FORM 12-A (REVISED) (TO BE FILLED IN BY THE EPFO)
EMPLOYEES' PROVIDENT FUND AND MISC PROVISIONS ACT 1952
EMPLOYEES' PENSION SCHEME[PARAGRAPH 20(4)}
NAME AND ADDRESS OF THE ESTT
0 CURRENCY PERIOD FROM IST APRIL 2004 TO 31ST MARCH-2005 ESTABLISHMENT STATUS
STATEMENT OF CONTRIBUTION FOR THE MONTH OF NOVEMBER-2004 GROUP CODE
STATUTORY RATE OF CONTIBUTION 12%
CODE NO
PARTICULARS WAGES ON AMOUNT OF CONTRIBUTION AMOUNT OF CONTRIBUTION REMITTEDAMOUNT OF AMOUNT OF
WHICH 3 4 adminitrative adminitrative
CONTRIBUTIONS Recovered from Payable by Worker's share Employer's Share charges charges
ARE PAYABLE the workers the employer due remitted
1 2 5 6

E.P.F. A/C NO. 01 0 0 0 0 0 0 0

PENSION FUND 0 NIL 0 NIL 0 NIL NIL

A/C NO. 10

D.L.I. A/C NO.21 0 NIL 0 NIL 0 0 0

TOTAL NO OF EMPLOYEES 124
(A)CONTRACT NAME AND ADDRESS OF THE
(B)REST BANK WHICH THE AMOUNT IS
© TOTAL 124 REMITTED
DETAILS OF E.P.F. PENSION EDLI
SUBSCRIBERS FUND
NO OF SUBSCRIBERS AS PER LAST MONTH
NO OF NEW SUBSCRIBERS(VIDE FORM 5) 0
NO OF SUBSCRIBERS LEFT SERVICES(VIDE FORM 10)
(NETT.) TOTAL NO OF SUBSCRIBERS
Authorised Signatory
ESTABLISHMENT STATUS
GROUP CODE

DATE OF REMITTANCE
(enclose triplicate copies of
challan)

| 12 | 2 0 0 4 |

| 12 | 2 0 0 4 |

| 12 | 2 0 0 4 |

Authorised Signatory
 THE EMPLOYEES' PROVIDENT FUND SCHEME 1952 FORM NO. 5
[PARAGRAPH 36(2)(a) & (b)]
Details of Employees qualifyind for membership of the fund for the first time during the month of September-04
(to be sent to the commissioner with form 2)
Name and address of the Factory/Estt 0 CODE NO OF FACTORY/ESTABLISHMENT : DL/24163
0
SL ACCOUNT NAME OF THE FATHER'S DATE OF TOTAL PERIOD OF REMARKS
NO. NO. EMPLOYEE NAME(OR AGE ELEGIBILI PREVIOUS SERVICE
IN BLOCK HUSBAND'S TY FOR (EXCLUDING PERIOD
LETTER NAME IN NEW OF BREAK) AS ON
CASE OF MEMBER THE DATE OF
MARRIED DATE OF JOINING THE FUNDS
WOMEN JOINING
IN CASE
OF OLD
MEMBER
1 2 3 4 5 6 7 8
1
2
3 NIL
4
5
6
7
8

DATE 0
ALSO FILL IN FORM NO 10 OVERLEAF

Authorised Signatory
 THE EMPLOYEES' PROVIDENT FUND SCHEME 1952 FORM NO. 10
[PARAGRAPH 36(2)(b)]
RETURN OF MEMBERS LEAVING SERVICE DURING THE MONTH OF SEPTEMBER-2004

Name and address of the Factory/Estt 0 CODE NO OF FACTORY/ESTABLISHMENT: DL/24163

0
SL ACCOUNT NAME OF THE FATHER'S NAME (OR DATE OF REASON REMARKS
NO. NO. EMPLOYEE[IN BLOCK HUSBAND'S NAME IN CASE LEAVING OF
LETTER OF MARRIED WOMEN SERVICE LEAVING

1 2 3 4 5 6 7
1
2 NIL
3
4
5
6
7
8
DATE 0

Authorised Signatory
Please state whether the member is (a) retiring according to para 69(1) (a) (b) of the scheme (b) leaving India for permanent settlement abroad
©retrenchment(d)ordinarily dismissed for serious an willful misconduct (e) discharge(f)resigning from or leaving service(g)taking up employment
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 certificate
"Certified that the member mentioned at seriol No._____ Shri _____________ was dismissed for serious and willful misconduct. I recommend
that the Employer's contribution for ____________ should be forfeited from the account in the fund. A copy of the order of dismissed
is enclosed."
"Certified that the member mentioned at seriol No._____ Shri _____________ was paid/not paid retrenchment compensation of Rs.
under the Industrial Dispute Act 1947."
Also fill in form no. 5 overleaf
0
Authorised Signatory