(1) On commencement of this Scheme, the Employees' Family Pension Scheme, 1971, in force immediately before such commencement shall cease to operate with effect from the 16th November, 1995.
(2) Notwithstanding anything contained in sub-paragraph (1) every nomination made under the Employees' Family Pension Scheme, 1971, and every form regarding the details of family of an employee for the purposes of the Employees' Family Pension Scheme, 1971, shall be deemed to have been made under the provisions of this Scheme.
(3) All orders/authorisations/Pension Payment Orders issued under the Family Pension Scheme, 1971, shall be deemed to have been made under this Scheme.
TABLE A
(See Paragraph 14)
Withdrawal Benefit
| No. of full years contribution paid |
Proportion of pay payable at cessation of membership |
| (1) |
(2) |
| 1 |
0.20 |
| 2 |
0.41 |
| 3 |
0.62 |
| 4 |
0.84 |
| 5 |
1.06 |
| 6 |
1.29 |
| 7 |
1.51 |
| 8 |
1.75 |
| 9 |
1.98 |
| 10 |
2.23 |
| 11 |
2.47 |
| 12 |
2.72 |
| 13 |
2.98 |
| 14 |
3.24 |
| 15 |
3.51 |
| 16 |
3.78 |
| 17 |
4.05 |
| 18 |
4.34 |
| 19 |
4.62 |
| 20 |
4.92 |
| 21 |
5.21 |
| 22 |
5.52 |
| 23 |
5.83 |
| 24 |
6.14 |
| 25 |
6.46 |
| 26 |
6.79 |
| 27 |
7.12 |
| 28 |
7.46 |
| 29 |
7.81 |
| 30 |
8.16 |
| 31 |
8.52 |
| 32 |
8.89 |
| 33 |
9.26 |
| 34 |
9.64 |
| 35 |
10.03 |
| 36 |
10.43 |
| 37 |
10.83 |
| 38 |
11.24 |
| 39 |
11.66 |
| 40 |
12.08 |
84[TABLE B
(See Paragraphs 12 and 14)
Factor for computation of past service benefit under the ceased family pension scheme for existing members on exit from the employment
| Years |
Factor |
Years |
Factor |
| 1 |
2 |
1 |
2 |
| Less than 1 |
1.039 |
Less than 18 |
3.845 |
| Less than 2 |
1.122 |
Less than 19 |
4.152 |
| Less than 3 |
1.212 |
Less than 20 |
4.485 |
| Less than 4 |
1.309 |
Less than 21 |
4.843 |
| Less than 5 |
1.413 |
Less than 22 |
5.231 |
| Less than 6 |
1.526 |
Less than 23 |
5.649 |
| Less than 7 |
1.649 |
Less than 24 |
6.101 |
| Less than 8 |
1.781 |
Less than 25 |
6.589 |
| Less than 9 |
1.923 |
Less than 26 |
7.117 |
| Less than 10 |
2.077 |
Less than 27 |
7.686 |
| Less than 11 |
2.243 |
Less than 28 |
8.301 |
| Less than 12 |
2.423 |
Less than 29 |
8.965 |
| Less than 13 |
2.616 |
Less than 30 |
9.682 |
| Less than 14 |
2.826 |
Less than 31 |
10.457 |
| Less than 15 |
3.052 |
Less than 32 |
11.294 |
| Less than 16 |
3.296 |
Less than 33 |
12.197 |
| Less than 17 |
3.560 |
Less than 34 |
13.173] |
TABLE C
(See Paragraph 16)
Equivalent Widow Pension
| Salary at day of death not more than |
Equivalent widow pension |
| (1) |
(2) |
| [Rupees] |
[Rupees] |
| Up to 300 |
250 |
| 350 |
327 |
| 400 |
343 |
| 450 |
359 |
| 500 |
375 |
| 550 |
391 |
| 600 |
408 |
| 650 |
425 |
| 700 |
442 |
| 750 |
459 |
| 800 |
476 |
| 850 |
493 |
| 900 |
510 |
| 950 |
527 |
| 1000 |
544 |
| 1050 |
561 |
| 1100 |
578 |
| 1150 |
595 |
| 1200 |
612 |
| 1250 |
629 |
| 1300 |
646 |
| 1350 |
664 |
| 1400 |
682 |
| 1450 |
700 |
| 1500 |
718 |
| 1550 |
736 |
| 1600 |
754 |
| 1650 |
772 |
| 1700 |
797 |
| 1750 |
808 |
| 1800 |
826 |
| 1850 |
844 |
| 1900 |
862 |
| 1950 |
880 |
| 2000 |
898 |
| 2050 |
916 |
| 2100 |
935 |
| 2150 |
954 |
| 2200 |
973 |
| 2250 |
992 |
| 2300 |
1011 |
| 2350 |
1030 |
| 2400 |
1049 |
| 2450 |
1068 |
| 2500 |
1087 |
| 2550 |
1106 |
| 2600 |
1125 |
| 2650 |
1144 |
| 2700 |
1163 |
| 2750 |
1182 |
| 2800 |
1201 |
| 2850 |
1221 |
| 2900 |
1241 |
| 2950 |
1261 |
| 3000 |
1281 |
| 3050 |
1301 |
| 3100 |
1321 |
| 3150 |
1341 |
| 3200 |
1361 |
| 3250 |
1381 |
| 3300 |
1401 |
| 3350 |
1421 |
| 3400 |
1441 |
| 3450 |
1461 |
| 3500 |
1481 |
| 85[3550 |
1501 |
| 3600 |
1521 |
| 3650 |
1541 |
| 3700 |
1561 |
| 3750 |
1581 |
| 3800 |
1601 |
| 3850 |
1621 |
| 3900 |
1641 |
| 3950 |
1661 |
| 4000 |
1681 |
| 4050 |
1701 |
| 4100 |
1721 |
| 4150 |
1741 |
| 4200 |
1751 |
| 4250 |
1761 |
| 4300 |
1771 |
| 4350 |
1781 |
| 4400 |
1791 |
| 4450 |
1801 |
| 4500 |
1811 |
| 4550 |
1821 |
| 4600 |
1831 |
| 4650 |
1841 |
| 4700 |
1851 |
| 4750 |
1861 |
| 4800 |
1871 |
| 4850 |
1881 |
| 4900 |
1891 |
| 4950 |
1896 |
| 5000 |
1901 |
| 5050 |
1906 |
| 5100 |
1911 |
| 5150 |
1916 |
| 5200 |
1921 |
| 5250 |
1926 |
| 5300 |
1931 |
| 5350 |
1936 |
| 5400 |
1941 |
| 5450 |
1946 |
| 5500 |
1951 |
| 5550 |
1956 |
| 5600 |
1961 |
| 5650 |
1966 |
| 5700 |
1971 |
| 5750 |
1976 |
| 5800 |
1981 |
| 5850 |
1986 |
| 5900 |
1991 |
| 5950 |
1996 |
| 6000 |
2001 |
| 6050 |
2006 |
| 6100 |
2011 |
| 6150 |
2016 |
| 6200 |
2021 |
| 6250 |
2026 |
| 6300 |
2031 |
| 6350 |
2036 |
| 6400 |
2041 |
| 6450 |
2046 |
| 6500 |
2051] |
| 86[6550 |
2056 |
| 6600 |
2061 |
| 6650 |
2066 |
| 6700 |
2,071 |
| 6750 |
2076 |
| 6800 |
2081 |
| 6850 |
2086 |
| 6900 |
2091 |
| 6950 |
2096 |
| 7000 |
2101 |
| 7050 |
2106 |
| 7100 |
2111 |
| 7150 |
2116 |
| 7200 |
2121 |
| 7250 |
2126 |
| 7300 |
2131 |
| 7350 |
2136 |
| 7400 |
2141 |
| 7450 |
2146 |
| 7500 |
2151 |
| 7550 |
2156 |
| 7600 |
2161 |
| 7650 |
2166 |
| 7700 |
2171 |
| 7750 |
2176 |
| 7800 |
2181 |
| 7850 |
2186 |
| 7900 |
2191 |
| 7950 |
2196 |
| 8000 |
2201 |
| 8050 |
2206 |
| 8100 |
2211 |
| 8150 |
2216 |
| 8200 |
2221 |
| 8250 |
2226 |
| 8300 |
2231 |
| 8350 |
2236 |
| 8400 |
2241 |
| 8450 |
2246 |
| 8500 |
2251 |
| 8550 |
2256 |
| 8600 |
2261 |
| 8650 |
2266 |
| 8700 |
2271 |
| 8750 |
2276 |
| 8800 |
2281 |
| 8850 |
2286 |
| 8900 |
2291 |
| 8950 |
2296 |
| 9000 |
2301 |
| 9050 |
2306 |
| 9100 |
2311 |
| 9150 |
2316 |
| 9200 |
2321 |
| 9250 |
2326 |
| 9300 |
2331 |
| 9350 |
2336 |
| 9400 |
2341 |
| 9450 |
2346 |
| 9500 |
2351 |
| 9550 |
2356 |
| 9600 |
2361 |
| 9650 |
2366 |
| 9700 |
2371 |
| 9750 |
2376 |
| 9800 |
2381 |
| 9850 |
2386 |
| 9900 |
2391 |
| 9950 |
2396 |
| 10,000 |
2401 |
| 10,050 |
2406 |
| 10,100 |
2411 |
| 10,150 |
2416 |
| 10,200 |
2421 |
| 10,250 |
2426 |
| 10,300 |
2431 |
| 10,350 |
2436 |
| 10,400 |
2441 |
| 10,450 |
2446 |
| 10,500 |
2451 |
| 10,550 |
2456 |
| 10,600 |
2461 |
| 10,650 |
2466 |
| 10,700 |
2471 |
| 10,750 |
2476 |
| 10,800 |
2481 |
| 10,850 |
2486 |
| 10,900 |
2491 |
| 10,950 |
2496 |
| 11,000 |
2501 |
| 11,050 |
2506 |
| 11,100 |
2511 |
| 11,150 |
2516 |
| 11,200 |
2521 |
| 11,250 |
2526 |
| 11,300 |
2531 |
| 11,350 |
2536 |
| 11,400 |
2541 |
| 11,450 |
2546 |
| 11,500 |
2551 |
| 11,550 |
2556 |
| 11,600 |
2561 |
| 11,650 |
2566 |
| 11,700 |
2571 |
| 11,750 |
2576 |
| 11,800 |
2581 |
| 11,850 |
2586 |
| 11,900 |
2591 |
| 11,950 |
2596 |
| 12,000 |
2601 |
| 12,050 |
2606 |
| 12,100 |
2611 |
| 12,150 |
2616 |
| 12,200 |
2621 |
| 12,250 |
2626 |
| 12,300 |
2631 |
| 12,350 |
2636 |
| 12,400 |
2641 |
| 12,450 |
2646 |
| 12,500 |
2651 |
| 12,550 |
2656 |
| 12,600 |
2661 |
| 12,650 |
2666 |
| 12,700 |
2671 |
| 12,750 |
2676 |
| 12,800 |
2681 |
| 12,850 |
2686 |
| 12,900 |
2691 |
| 12,950 |
2696 |
| 13,000 |
2701 |
| 13,050 |
2706 |
| 13,100 |
2711 |
| 13,150 |
2716 |
| 13,200 |
2721 |
| 13,250 |
2726 |
| 13,300 |
2731 |
| 13,350 |
2736 |
| 13,400 |
2741 |
| 13,450 |
2746 |
| 13,500 |
2751 |
| 13,550 |
2756 |
| 13,600 |
2761 |
| 13,650 |
2766 |
| 13,700 |
2771 |
| 13,750 |
2776 |
| 13,800 |
2781 |
| 13,850 |
2786 |
| 13,900 |
2791 |
| 13,950 |
2796 |
| 14,000 |
2801 |
| 14,050 |
2806 |
| 14,100 |
2811 |
| 14,150 |
2816 |
| 14,200 |
2821 |
| 14,250 |
2826 |
| 14,300 |
2831 |
| 14,350 |
2836 |
| 14,400 |
2841 |
| 14,450 |
2846 |
| 14,500 |
2851 |
| 14,550 |
2856 |
| 14,600 |
2861 |
| 14,650 |
2866 |
| 14,700 |
2871 |
| 14,750 |
2876 |
| 14,800 |
2881 |
| 14,850 |
2886 |
| 14,900 |
2891 |
| 14,950 |
2896 |
| 15,000 or more |
2901 |
Note. 87[* * *]
88[TABLE D
(See Paragraph 14)
Return of contribution on exit from the employment
| Years of service |
Proportion of wages at exit |
| 1 |
1.02 |
| 2 |
1.99 |
| 3 |
2.98 |
| 4 |
3.99 |
| 5 |
5.02 |
| 6 |
6.07 |
| 7 |
7.13 |
| 8 |
8.22 |
| 9 |
9.33 |
Note. The above table is based on a flat addition in benefit.]
89[TABLE E
(See Paragraph 39-B)
(Transfer value of contribution from Employees' Pension Scheme, 1995 to exempted or other pension fund and vice-versa)
| Number of full year's contribution paid |
Proportion of pay on last contribution month |
Number of full year's contribution paid |
Proportion of pay on last contribution month |
| 1. |
0.987 |
13. |
14.841 |
| 2. |
1.998 |
14. |
16.182 |
| 3. |
3.033 |
15. |
17.554 |
| 4. |
4.093 |
16. |
18.960 |
| 5. |
5.178 |
17. |
20.399 |
| 6. |
6.289 |
18. |
21.872 |
| 7. |
7.426 |
19. |
23.380 |
| 8. |
8.590 |
20. |
24.924 |
| 9. |
9.782 |
21. |
26.505 |
| 10. |
11.003 |
22. |
28.123 |
| 11. |
12.252 |
23. |
29.780 |
| 12. |
13.531 |
24. |
31.477] |
90[Form 1
[See Paragraph 39-A]
Monthly Return to be submitted by the exempted establishments/class of establishments/Board of Trustees
| 1. |
DETAILS OF ESTABLISHMENTS: |
| |
(a) Name of the establishment with full address: |
| |
(b) Code No. allotted by the Employees Provident Fund Organisation: |
| 2. |
DETAILS OF EMPLOYEES (INCLUDE ALL BRANCHES/UNITS ETC.) |
| |
(a) No. of employees as at the end of previous month |
|
| |
(b) No. of employees who joined during the month |
|
| |
(c) No. of employees who left service during the month |
|
| |
(d) No. of employees as at the end of the month |
|
| |
[(a)+(b) (c)] |
|
| |
(e) Out of (d) above, No. of excluded employees |
|
| |
(f) No. of Pension Fund members as at the end of the month |
|
| |
(Please furnish the above-mentioned details unitwise situated at different places. Attach separate sheet, if necessary) |
|
| 3. |
CONSTITUTION OF BOARD OF TRUSTEES: |
|
| |
(a) Date on which the present Board was constituted: |
|
| |
|
|
| |
|
DDMMYYYY |
| |
Its term: |
Years |
| |
Total number of Trustees: |
|
| |
(i) Employees' Representatives |
|
| |
(ii) Employer's Representatives |
|
| 4. |
WAGES CONTRIBUTIONS, ETC. |
|
| |
(a) Amount of gross wages liable to Pension Contribution |
Rs. |
| |
(b) Rate of contribution to Pension Fund |
% |
| |
(c) Amount of Pension contribution to be transferred for the |
|
| |
current month |
Rs. |
| |
(d) Amount of arrears due, if any, for transfer to the Board |
|
| |
of Trustees at the end of the previous month |
Rs. |
| |
(e) Total of (c) & (d) |
Rs. |
| |
(f) Amount actually transferred to the Board of Trustees |
Rs. |
| |
(g) Balance due, if any, for transfer to the Board of Trustees |
|
| |
[(e)-(f)] |
Rs. |
| |
(h) Whether the interest payable under Section 7-Q of the Act |
|
| |
for the belated transfer of Funds, if any, has been paid? |
Yes |
| |
(i) Amount of interest still payable at the end of the month |
No |
| |
|
Rs. |
| 5. |
DETAILS OF PENSIONERS |
|
| |
(a) No. of Pensioners at the end of the month: |
|
| |
(i) Member (Self) Pensioners: |
|
| |
- Superannuation Pension |
|
| |
- Early Pension |
|
| |
- Disablement Pension |
|
| |
(ii) Spouse Pensioners: |
|
| |
- Death in service |
|
| |
- Death away from service |
|
| |
- Death as pensioner |
|
| |
(iii) Children Pensioner: |
|
| |
- Normal Children |
|
| |
- Disabled Children |
|
| |
(Lifelong pension) |
|
| |
(iv) Orphan Pensioner |
|
| |
(v) Nominee Pensioner |
|
| |
(vi) Dependent parents pensioner |
|
| |
(b) Total amount of Pension paid during the month: |
Rs. |
| 6. |
DETAILS OF EXIT CASES |
|
| |
(a) No. of persons who have taken withdrawal benefit during the month |
|
| |
(b) Amount paid during the month |
Rs. |
| |
No. of exit cases where Scheme Certificate has been issued |
|
| 7. |
DETAILS OF INVESTMENT |
|
| |
(a) Amount lying invested in the Pension Fund in the |
|
| |
beginning of the month: |
Rs. |
| |
(b) Amount received during the month: |
|
| |
(i) By way of Contribution from the employer |
|
| |
- Current month |
Rs. |
| |
- Arrears, if any |
Rs. |
| |
(ii) Encashment of matured securities/deposits |
Rs. |
| |
(iii) Interest/dividend on investments |
Rs. |
| |
(iv) Other transfer-in-cases |
Rs. |
| |
(v) Damages, if any |
Rs. |
| |
(vi) Interest on belated payment, if any |
Rs. |
| |
(vii) Miscellaneous, if any |
Rs. |
| |
(Please specify) |
|
| |
(c) Payments made during the month: |
Rs. |
| |
(d) Amount invested during the month: |
Rs. |
| |
Securities: |
|
| |
- Central Government |
Rs. |
| |
- State Government |
Rs. |
| |
- Others, if any |
Rs. |
| |
Deposits. |
|
| |
- Public Financial Institutions/Banks |
Rs. |
| |
(e) Whether pattern of investment followed? |
Yes |
| |
|
No |
| |
(f) If so, classify the percentage: |
|
| |
(i) Securities: |
|
| |
- Central Government |
% |
| |
- State Government |
% |
| |
- Others |
% |
| |
(ii) Deposits: |
|
| |
- Public Financial Institutions/Banks |
% |
| |
(iii) Annuity purchased from Life Insurance Corporation |
Rs. |
| |
(g) Amount lying un-invested in Cash/Bank |
Rs. |
| 8. |
MODE OF DISBURSEMENT |
|
| |
[ Tick one] |
|
| |
- Through Bank |
|
| |
- Through Post Offices |
|
| |
- Through LIC by purchase of Annuity |
|
| |
- Others, if any, (Please specify) |
|
| 9. |
RULES OF ESTABLISHMENT's PENSION FUND |
|
| |
Details of amendment, if any carried out during the |
|
| |
month to make the Rules at par with the Statutory |
|
| |
Pension Scheme (Employees' Pension Scheme 1995) |
| Date |
Signature with official seal of the Employer/ |
| |
Trustees of the Board] |
Form 2
Declaration and Nomination Form under the Employees' Provident Fund and Employees' Pension Scheme
[Paragraphs 33 & 61(1) of the Employees' Provident Funds Scheme, 1952 and Paragraph 18 of the Employees' Pension Scheme, 1995]
1. Name (in block letters)
2. Father's/Husband's Name
3. Date of Birth
4. Sex
5. Marital Status
6. Account No.
7. Address
Permanent
Temporary
8. (A) Date of Joining of EPF Scheme, 1952
(B) Date of Joining of EPF Scheme, 1971
(C) Date of Joining of EPF Scheme, 1995
PART A (EPF)
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate the person(s), mentioned below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death:
| Name of the nominee/nominees |
Address |
Nominee's relationship with the member |
Date of Birth |
Total amount or share of accumulations in Provident Fund to be paid to each nominee |
If the Nominee is a minor, name & relationship & address of the guardian who may receive the amount during the minority of nominee |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
| |
|
|
|
|
|
1. *Certified that I have no family as defined in Para 2(g) of the Employees' Provident Funds Scheme, 1952 and should I acquire a family hereafter the above nomination should be deemed as cancelled.
2. *Certified that my father/mother is/are dependant upon me.
*Strike out whichever is not applicable.
Signature or thumb-impression of the subscriber.
PART B (EPS)
(Para 18)
I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension in the event of my death.
| Sl. No. |
Name & Address of the family members |
Address |
Date of Birth |
Relationship with the member |
| (1) |
(2) |
(3) |
(4) |
(5) |
| 1. |
|
|
|
|
| 2. |
|
|
|
|
| 3. |
|
|
|
|
*Certified that I have no family as defined in Para 2(vii) of the Employees' Pension Scheme, 1995 and should I acquire a family hereafter I shall furnish particulars thereon in the above form.
I hereby nominate the following person for receiving the monthly widow pension admissible under Para 16(2)(a)(i) & (ii) in the event of my death without leaving any eligible family member for receiving pension.
| Name & Address of the nominee |
Date of Birth |
Relationship with the member |
| |
|
|
Date:
*Strike out whichever is not applicable.
Signature or thumb-impression of the subscriber.
CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb-impressed before me by Shri/Smt/Km employed in my establishment after he/she has read the entries. The entries have been read over to him/her by me and got confirmed by him/her.
| |
Signature of the employer or other authorised officers of the establishment |
| Place |
Designation |
| Date |
Name and Address of the Factory/Establishment or rubber stamp thereof. |
Form 3
(For Exempted Establishments)
[Paragraph 20(1) of The Employees' Pension Scheme, 1995]
Code No. of the Estt
Consolidated return of employees who are entitled and required to become members of the Pension Fund on the date the Pension Scheme comes into force.
Name and address of Establishment Date of Coverage
Industry in which the Estt. is engaged Registration No. of the Estt
| Sl. No. |
Account No. |
Name of the emplo-yee (in block capitals) |
Father's Name (or hus-band's name in the case of married woman) |
Basic wages D.A. including cash value of food concession & retaining allowance if any |
Date of Birth |
Sex |
Date of entitlement for membership |
Remarks |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
| |
|
|
|
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| Date |
Signature of the employer or other |
| Station |
authorised officer |
The information received in Form 5 (PS) in respect of the members leaving service shall be entered in this form by Commissioner specifying clearly the reason for leaving service.
Stamp of the Establishment
Note: This form should be accompanied by declaration in Form 2 by every employee mentioned in Column 3.
Form 4 (EPS)
[See Paragraph 20]
THE EMPLOYEES' PENSION SCHEME, 1995
(For Exempted Establishments only)
Return of Employees entitled for membership of the Employees' Pension Fund during the month of 20
Name and Address of the Establishment
Code No. of the Establishment TN/
| Account No. |
Name of the employee (in block capitals) |
Father's Name or Husband's Name (in case of married woman) |
Age at entry |
Sex |
Date of entitlement for membership |
Remarks, Previous Account No. and particulars of previous service, if any |
| 2 |
3 |
4 |
5 |
6 |
7 |
8 |
| Date |
Stamp of the Establishment |
Signature of the Employer or other authorised Officer of the Establishment |
Note. An employee who has attained 58 years and/or for drawing Pension under the EPS-95 is not to be enrolled as a member.
Form 5 (EPS)
[See Paragraph 20(2)]
THE EMPLOYEES' PENSION SCHEME, 1995
(For Exempted Establishments only)
Return of Members leaving service during the month of 20.
Name and Address of the Establishment
Code No of me Establishment
| Sl. No. |
Account No. |
Name of the member (in block capitals) |
Father's Name or Husband's Name (in case of married woman) |
Date of leaving service |
Reason for leaving service (See note given below) |
Remarks |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| |
|
|
|
|
|
|
Signature of the Employer
Stamp of the Establishment
Note An employee who has attained the age of 58 years will cease to be 3 member of die Scheme and entitled to receive the due benefit under the Employees' Pension Scheme. 1995.
Form 6
[Paragraph 20 of The Employees' Pension Scheme, 1995]
(For Exempted Establishment only) Total No. of Employees . (ContractRestTotal)
Statement of Contribution for the month of . 20 .
Total No. of Subscribers
Name and Address of the Establishment
Currency period from 1st April, 20 to 31st March, 20
Code No. of the Establishment . Statutory Rate of Contribution 8.33% .
| Total No. of Subscribers |
Wages on which contributions are payable |
Amount of contribution due 8.33% |
Amount of contribution remitted in A/c. No. 10 |
Date of Remittance (Triplicate copy of the challan to be enclosed.) |
Name & Address of the bank in which amt. is remitted |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
| |
|
|
|
|
|
No. of Sub. as per last month's return .
Add. No. of New Subscribers vide Form 4 (PS) .
Less No. of Subscribers left service vide Form 5 (PS)
Signature of the Employer
(with official seal)
Net total:
(This should tally with the figures given in Col. 1)
Note: (1) If there is any substantial variation between the wages & contribution shown above and those shown in the last month's return, suitable explanation should be given in the Remarks column.
(2) If any arrears of contributions or damages are included in the figures under Column 4 suitable details indicating the circumstances, amount, No. of Subscribers and the period involved should be furnished in the Remarks column or on the reverse.
Date:
Form 7
[Paragraph 19 of The Employees' Pension Scheme, 1995]
(For Exempted Establishment only)
Contribution card for members for the year 20 . .20
(1) A/c. No
(2) Name (in block Capitals)
(3) Father's/Husband's Name
(4) Name & Address of the Establishment
(5) Statutory rate of contribution 6 %/8%
(6) Voluntary higher rate of employee's contribution, if any
(7) Date of Commencement of membership of the Family Pension Fund
| Month |
Amount of wages, retaining allowance, if any & DA including cash value offood concession paidduring the month |
Contribution to Pension Fund |
Remarks |
| Empl-oyee's share Rs. |
Empl-oyer's share Rs. |
| (1) |
(2) |
(3) |
(4) |
(5) |
| April, 20 |
|
|
|
|
| May |
|
|
|
(a) Date of leaving service. |
| June |
|
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|
| July |
|
|
|
| August |
|
|
|
| Sept. |
|
|
|
| Oct. |
|
|
|
(b) Reason for leaving service .. |
| Nov. |
|
|
|
| Dec. |
|
|
|
| Jan. |
|
|
|
| Feb. |
|
|
|
| March |
|
|
|
| |
Rs. |
Rs. |
Rs. |
|
Certified that the difference between the total contributions shown under Col. (3) and (4) of the above and that arrived at the total wages shown in Col. (2) at the prescribed rate is solely due to the rounding off of contribution to the nearest rupee under the rules.
Certified that the total amount of contributions indicated under Col. (3) + Col. (4) i.e. Rs . has already been remitted in full in F.P.F. Account No. 10 (Family Pension Fund Contribution).
Date ..20 .
Signature of employer
(Office Seal)
Form 8
(For Exempted Establishments only)
[Paragraph 20 of The Employees' Pension Scheme, 1995]
Annual statement of Contribution for the currency period from 1st 20 to .. 20
Name & Address of the Establishment .
Code No. of the Establishment
| Sl. No. |
Account No. |
Name of member (in block letters) |
Wages, retaining allowances (if any) and D.A. including cash value of food concession paid during the currency period |
Contribution to Pension Fund 8.33% (Rs) |
Remarks |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
| |
|
|
|
|
|
Reconciliation of Remittances asTotalRs.Rs.
Sl. No.MonthPension Fund Contribution A/c No. 10
| 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. |
Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. |
Certified that the difference between the figures of total Pension Fund Contributions remitted during the currency period & the total Pension Fund Contribution shown under Col. 5 is solely due to the rounding off of amounts to the nearest Rupee under the rules. |
(i) (ii) |
Total number of contribution cards enclosed in Form 7 (PS). Certified that Form 7 (PS) completed of all the members listed in this statement are enclosed, except those already sent during the course of the currency period for the final settlement of the concerned members account Remarks furnished against the names of the respective member I above. |
| Total |
Rs. |
Signature of the Employer (with Office Seal) |
|
Note: (1) The names of all members, including those who had left service during the currency period should be included in this statement, where the Form 7 (PS) in respect of such members who had left service were already sent to the Regional office for the purpose of final settlement of their accounts, the fact should be stated against the members in the Remarks column above this Form 7 (PS) already sent in the month of .20
(2) In case of actual variation in the wages contributions of any members as required in lines shown in previous statement the reason should be explained adequately in the Remarks column.
Form 9
(For Exempted Establishments only)
[Paragraph 24 of The Employees' Pension Scheme, 1995]
Declaration by a person taking up employment in the establishment
I .. S/o/W/o/Daughter of do hereby solemnly declare that:
(a) I was employed in M/s . (Name & Full address of the establishment) with PF A/c No . and left service on Prior to that, I was employed in with PF A/c No . from to .
(b) I am a member of the Pension Fund from . . to . . and copy of the Scheme Certificate is enclosed.
(c) I have/have not withdrawn the amount of my Provident Fund/Pension Fund.
(d) I have/have not drawn any benefits under the Employees' Pension Scheme, 1995 in respect of my past service, in any establishment.
(e) I have/have never been a member of any Provident Fund and/or Pension Fund.
Date ..
*Signature or left-hand thumb
impression of the employee.
Encl: Copy of Scheme Certificate.
(To be filled by the Employer)
| (1) Shri . is appointed as .. |
| (Name of Employee) |
(Designation) |
| in M/s .. with effect from . |
| (Name of the Factory/Establishment) |
(Date of appointment) |
(2) Copy of the Scheme Certificate is enclosed.
(3) Declaration & nomination in Form 2 is enclosed.
Dated:
Signature of the Employer or Manager or other Authorised Officer
Left-hand thumb-impression in the case of illiterate male member and right-hand thumb-impression by illiterate female member.
Form 10-C
EMPLOYEES' PENSION SCHEME, 1995
form to be used by a member of the Employees' Pension Scheme, 1995 for claiming withdrawal benefit/Scheme Certificate
(Read the instruction before filling up this form)
| 1. |
(a) Name of the member (in block letters) (b) Name of the Claimant(s) |
| 2. |
Date of Birth |
| 3. |
(a) Father's Name (b) Husband's Name (if applicable) |
| 4. |
Name & Address of the Establishment |
|
| |
in which the member was last employed |
Region S.R.O. Code |
| 5. |
Code No. & Account No. U.P./ |
Estt. Code No. A/c No. |
| |
|
|
| 6. |
Reason for leaving service & . |
| |
Date of leaving . |
| 7. |
Full Postal Address (in block letters) . |
| |
Shri/Smt/Kumari |
| 8. |
Are you willing to accept Scheme |
Yes No |
| |
Certificate in lieu of withdrawal benefits |
| 9. |
Particulars of Family (Spouse, Children & Nominee) |
| Name |
Date of Birth |
Relationship with Member |
Name of the guardian of minor |
| a. Family Members |
|
|
|
| b. Nominee |
|
|
|
| 10. |
In case of Death of member after attaining the age of 58 years without filling the claim form: |
| |
(a) Date of death of member (b) Name of the Claimant(s)/and relationship with the members |
| 11. |
MODE OF REMITTANCE: (PUT A TICK ( ) IN THE BOX AGAINST THE ONE OPTED |
|
| |
(a) By Postal money order at my cost to the address givenagainst Item No. 7. |
|
| |
(b) Account payee cheque sent direct to my S.B. A/c(Schedule Bank) under intimation to me. |
|
| |
S.B. Account No. |
|
| |
Name of the Bank (in block letters) |
|
| |
Branch (in block letters) |
|
| |
Full Address of the Branch (in block letters) |
|
| 12. |
Are you availing pension under |
| |
EPS-1995? If yes indicate |
PPO No. .By whom issued . |
| CERTIFICATE THAT PARTICULARS ARE TRUE TO THE BEST OF MY KNOWLEDGE |
| Date |
| Signature or left-hand thumb-impression of the member/claimant(s) |
ADVANCE STAMPED RECEIPT
[To be furnished only in case of (b) above]
Received a sum of Rs (Rupees . .) only from Regional Provident Fund Commissioner/Officer-in-charge of Sub-Regional Office . . by deposit in my Savings Bank Account towards the settlement of Pension Fund Account.
| (The space should be left blank which shall be filled by R.P.F.C./Officer-in-charge) Signature or left-hand thumb impression of the member on the revenue stamp |
Affix Re 1 Revenue Stamp |
| |
|
Certified that the particulars of the member given are correct and the member has signed/thumb-impressed before me.
The details of wages and period for non-contributory service of the member are as under:
(Form 3A/7 (FPS) enclosed for the period for which it was not sent to Employees' Provident Fund office)
Wages (Basic+D.A.) as on 15-11-95 (if applicable)
Wages as on the date of exit.
Period of Non-contributory Services
| Year/Month |
No. of days |
|
| Date: |
Signature of the Employer/Authorised Officer |
(FOR THE USE OF COMMISSIONER's OFFICE)
Under
Rs . . P.I. No . . . . M.O./Cheque
Passed for payments for Rs . . (In words) . . M.O. Commission (if any) . net amount to be paid by M.O . towards withdrawal benefit..
D.C S.S. . .A.A.O .
(FOR USE IN CASH SECTION)
Paid by inclusion Cheque No . . dt . . vide Cash Book (Bank) Account No. 10, Debit Item No ..
D.C .S.S. . .A.A.O A.P.F.C. (Cash.) ..
For issues of S.S.I.D.S. is enclosed.
D.C .S.S. . .A.A.O A.P.F.C. (A/cs.) ..
(FOR USE IN PENSION SECTION)
Scheme Certificate Bearing the control No. . . Issued No. .and entered in the Scheme Certificate Control Register.
D.C .S.S.. A.A.O A.P.F.C. (Pension) ..
Form 10-D
EMPLOYEES' PENSION SCHEME, 1995
Application for Monthly Pension
(Read INSTRUCTIONS91 before filling in this Form)
| 1. |
By whom the pension is claimed? |
|
| 2. |
Type of pension claimed. |
|
| 3. |
(a)Member's Name (In Block Letters) |
|
| |
(b)Sex |
|
| |
(c)Marital Status |
|
| |
(d)Date of Birth/Age |
|
| |
(e)Father's/Spouse's Name |
|
| 4. |
E.P.F. Account Number |
| |
R.O.S.R.O.Establishment Code No. |
| |
|
| |
Member's Account No. |
| |
|
| 5. |
Name & Address of the Establishment in which the member was last employed |
| 6. |
Date of leaving service |
| 7. |
Reason for leaving service |
| 8. |
Address for communication |
| |
. |
| |
|
| |
|
| |
. |
| (a) |
In Case of Reduced pension (early pension) Date of Option for commencement of pensionDateMonthYear |
| |
|
| 9. |
Option for commutation of 1/3 of Quantum Pension:YesNo |
| |
|
| |
(If option is for lesser commutation indicate the quantum) |
| 10. |
Option for Return of Capital: |
| |
(Please refer Serial Number 10 of INSTRUCTION)YesNo |
| |
[Put a tick ( )] |
| |
|
| |
If yes, indicate your choice of alternative 123 |
| 11. |
Mention your Nominee for Return of Capital: |
| |
Name: Relationship: Date of Birth: Address: |
12. Particulars of Family
| Sl. No. |
Name |
Date of Birth/Age |
Relationship with Member |
Indicate against Minor |
| Guardian 's Name |
Relation-ship with Member |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
| |
|
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| |
|
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| |
|
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| |
|
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Note: If any child is physically handicapped, please indicate DISABLED below the name.
13. Date of death of Member (If applicable):
14. Details of Savings Bank Account opened:
(1) Name of the Bank
(2) Name of the Branch:
(3) Full Postal Address:
(4) Pin Code:
| Sl. No. |
Name of the Claimant(s) |
Savings Bank Account No. |
| |
|
|
| 14. |
(A) If the claim is preferred by nominee, indicate his/her |
| |
(1)Name: |
| |
(2)Relationship with the deceased member: |
|
| 15. |
Details of Scheme Certificate already in: |
|
| |
possession of the Member, if any |
Scheme Certificate received & enclosed |
| |
|
|
| |
|
Not Received |
|
| |
|
Not Applicable |
|
| |
If received, indicate |
: |
|
| Sl. No. |
Scheme Certificate Control No. |
Authority who issued the Scheme Certificate |
| |
|
|
| |
|
|
|
|
| 16. |
If pension is being drawn under E.P.S., 1995: |
P.P.O. No. |
R.O. |
S.R.O. |
| |
|
issued by |
|
|
| 17. |
Documents enclosed: (Indicate as per the Instructions) |
|
| |
1. |
6. |
| |
2. |
7. |
| |
3. |
8. |
| |
4. |
9. |
| |
5. |
|
TO BE SUBMITTED IN DUPLICATE IN RESPECT OF EACH PERSON ELIGIBLE FOR PENSION
Descriptive roll of pensioner and his/her Specimen Signature/Thumb-impression.
| 1. |
Name of the Member |
: |
| 2. |
E.P.F. Account Number |
: |
| 3. |
Name of the Pensioner |
: |
| 4. |
Father's/Husband's Name |
: |
| 5. |
Sex |
: |
| 6. |
Nationality |
: |
| 7. |
Religion |
: |
| 8. |
Height |
: |
| 9. |
Personal Marks of Identification |
|
1. |
_____________________ |
| |
|
|
2. |
_____________________ |
| 10. |
Specimen signature of Pensioner |
: |
1. |
_____________________ |
| |
|
|
2. |
_____________________ |
| |
|
|
3. |
_____________________ |
(Only in the case of illiterate Claimant (Pensioner) Left-Hand Finger-Impression):
| THUMB |
INDEX |
MIDDLE |
RING |
SMALL |
| |
|
|
|
|
| |
Signature |
| Place: |
Name of the Attesting Authority |
| Date: |
Official Seal |
Certified that
(i) I am not drawing pension under Employees' Pension Scheme, 1995;
(ii) The particulars given in this application are true and correct.
Signature of the applicant/
Left hand thumb-impression.
(FOR OFFICE USE ONLY)
(PENSION SECTION/ACCOUNTS SECTION)
Certified that the particulars in the application have been verified with the relevant concerned documents. The claimant is eligible for pension. The Input Data Sheet is placed below for approval.
Entered in Form 9/Form 3 (PS) Master Ledger Card/Claim Inward Register.
Form 2(R) enclosed alongwith the documents furnished by the claimant.
| CLERK |
S.S. |
A.A.O. |
A.P.F.C. |
| Date |
Date |
Date |
Date |
FOR USE IN PENSION PRE-AUDIT CELL
The Input Data Sheet verified with reference to the application and the documents enclosed and found correct. P.P.O. may be generated through Computer.
| CLERK |
S.S. |
A.A.O. |
A.P.F.C. (Pension) |
| Date |
Date |
Date |
Date |
FOR USE IN PENSION DISBURSEMENT SECTION
| P.P.O. No. |
: |
| Date of issue to the Bank |
: |
| Intimation sent to the Claimant |
: |
| And also to Accounts Branch on |
: |
| CLERK |
S.S. |
A.A.O. |
A.P.F.C. |
| Date |
Date |
Date |
Date |
(TO BE FILLED BY THE EMPLOYER/AUTHORISED OFFICEROF THE ESTABLISHMENT)
Certified that:
(i) The particulars of the member are correct:
(ii) The particulars of Wages and Pension Contribution for the period of 12 months preceeding the date of leaving service are as under:
(In case, the wages is not earned for all 12 months, the block of 12 months will commence backwards from the last pay drawn.)
| Year |
Month |
Wages |
Pension Contribution due |
Details of period of non-contributory service. If there is no such period, indicate Nil |
| No. of Days |
Amount |
Year |
No. of days for which no wages were earned |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
| |
|
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| |
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| |
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Encl:
1. Documents as given in the Instructions.
2. Form of descriptive roll and specimen signature.
Signature of Employer/Authorised Official
of the Estt. with Seal & Date.
EXPLANATORY NOTE FOR THE APPLICATION:
Serial No. given below relates to the corresponding No. given in the application
1.By whom the pension is claimed?
Indicate any one of the following under Sl. No. 1
| Member |
Widow/Widower |
Major orphan |
Guardian |
Nominee |
| |
|
|
|
|
| 2. |
Type of Pension Claim Indicate any one of the following: |
| |
(a) On attaining 58 years |
|
| |
whether in service or not |
SUPERANNUATION PENSION |
| |
(b) Attained the age of 50 years but below 58 |
REDUCED PENSION |
| |
years and left service |
|
| |
(c) Left Service on account of total and |
|
| |
permanent disablement |
DISABLEMENT PENSION |
| |
(d) On death of member |
WIDOW & CHILDREN PENSION |
| |
(e) On death of parents or on remarriage |
|
| |
of the spouse, after the death of the member |
ORPHAN PENSION |
| |
(f) On death of the eligible children below |
|
| |
25 years on the date of death of the member |
NOMINEE PENSION |
3. (a) to (e), 4 & 5
Please furnish the particulars relating to the member correctly.
6. Indicate the actual date of leaving service. This need not be filled by a member who has attained 58 years and continued to be in service. Indicate, Still in service .
7. If the reason for leaving service was on account of total and permanent disablement, as indicated by the establishment to the P.F. Office through Form 10, then only the member is entitled for Disablement Pension. In all other cases the actual reason for leaving service may be given. However, a member who continues in service beyond the age of 58 years may indicate still in service .
8. If the present address is temporary one, also indicate permanent address.
9. Sl. No. 9 is applicable only to a member of the Pension Scheme and not for his family. The applicant is eligible to commute upto a maximum of 1/3 of his pension so as to receive 100 times of the pension commuted. If a pensioner who is getting an original pension of Rs 600/- commutes 1/3rd of it, he will get Rs 20,000 as commuted value. The commutation will be effective only from 16-11-1998. The applicant may give his option for commutation in the application and this will be effective and paid only if the member-pensioner continues to draw his pension as on 16-11-1998.
On opting for commuted value of pension, the original pension mentioned for Return of Capital will be the balance of pension after commutation.
10. The member can give his option for Return of Capital. Option once exercised is final. He may choose any one of the following and indicate the No. shown under alternative against Sl. No. 10 of the application.
| Alternative |
Quantum of pension |
Return of Capital |
| |
90% of original pension |
On member's death, 100 times the original monthly pension to nominee. |
| |
90% of original pension to member. On his/her death 80% of pension to Widow/Widower. |
On death or remarriage of Widow/Widower whichever is earlier 90 times of original pension to nominee. |
| |
87.5% of original pension for a fixed period of 20 years to member. On his death before 20 years, nominee will get pension for balance period. |
At the end of 20 years, 100 times of original pension to member, if he is alive, otherwise to nominee. |
11. The member is required to furnish the details of his/her nominee for receiving the Return of Capital. A member can nominate his/her spouse or sons or daughters. A married member who is not survived by any member of his family (spouse/sons/daughters) and a bachelor/spinster may nominate a person of his/her choice to receive the Return of Capital/pension due if any, under Alternative 3 as per Serial Number 10 above.
12. This should be completed by the member. In his absence, by the spouse/children. The list of surviving family members of the Member, covering his spouse, all children should be furnished. The particulars of Guardian should be given in respect of each minor child, as on the date of application. In support of the age of children, age proof certificate obtained from the School or Registrar of Births-deaths or E.S.I. Record, or Municipal authorities should be enclosed. In the case of Guardian other than natural guardian, a Guardianship Certificate should be enclosed.
13. Applicable only in case the member is not alive. In support to the date of death, Death Certificate should be enclosed.
14. The details of Bank Savings Bank Account Number should be given.
In case the claim is preferred by spouse, he/she should give his/her Savings Bank Account Number and also separate Savings Bank Account Numbers. In respect of each child Savings Bank Account Numbers of children who are below the age of 25 years (as on date of death of the member) should be given. On behalf of minor child, Savings Bank Account opened in the name of minor and operated by the guardian of the minor and Account Number should be given.
Pension is payable through any branch of the Punjab National Bank/State Bank of India on the specified day of each month by credit to the Savings Bank Account of eligible pensioners. Hence, Savings Bank Account should be opened only in the said Bank. Necessary guidelines have been given to all branches of the bank to open a Savings Bank Account for the Pensioners. The applicant may approach any branch of the said bank to open the account. The member, spouse and children (minor or major) should necessarily open Savings Bank Account in the same branch of the Bank.
Whenever pension is opted from a place beyond the jurisdiction of the Region in which the member was last employed, he should ascertain the name of the designated bank applicable in that Region and open a Savings Bank Account therein.
On sanction of Pension, intimation will be sent to the pensioner to contact the bank.
14.(A) In case of death of the member before attaining 58 years without leaving any eligible family members to receive the pension, the nominee as appointed by the member through Form 2 (Revised) already sent to the P.F. Office may apply giving his particulars against this column.
15. In case the member was working in different establishments and obtained Scheme Certificate, the details should be furnished against this column. In case, no Scheme Certificate was received or not applied for the same, the details of past employment may be indicated in this column.
16. If the applicant is already receiving pension under Employees' Pension Scheme, 1995, the details should be furnished against the column.
17. List of documents to be enclosed and specified under Column No. 17:
(a) Descriptive role of pensioner and his/her specimen Signature/Thumb impression duplicate;
(b) 3 passport size photographs (if claimed by the member joint photo with spouse). If the pension is claimed by member, there is no need to send photograph of the children. If claimed by widow/widower, the photograph should be sent for widow/widower and his/her two children (below 25 years) separately. The photographs are to be attested by the employer or his authorised official, indicating the person to whom the photograph relates and also the P.F. Account Number of the member, written on the reverse and placed in a separate envelope.
(c) In the case of member, who is permanently and totally disabled during the employment, he/she should undergo a Medical Examination before the medical board as advised by the E.P.F. Office. However, the disablement should occur while in employment.
(d) The application should be forwarded through the establishment in which the member last served/died. The establishment should furnish the certificate and wage particulars duly attested by the authorised officer.
(e) Only if the establishment is closed, the application should be forwarded through the Magistrate/Gazetted Officer/Bank Manager/any other authorised officer as may be approved by the Commissioner.
| (Supplied free of cost) ACKNOWLEDGMENT CARD |
| Account No. |
EPFO |
Office of the RPFC/Officer-in Charge of Sub-Regional Office |
| |
| |
| ACKNOWLEDGEMENT |
| Received the following claims: |
Registration No. . . . . . . . . . . . . . . . . . . . . . . . . . . |
| EPF |
Date Official Seal . . . . . . . . . . . . . . . . . . . . . . . . |
| FPF |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| IF |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| |
| In case, no intimation is received within a month, you may write to the Complaints Officer, Employees' Provident Fund duly quoting the Registration Number and your Provident Fund Account Number. |
POSTCARD |
Postage Prepaid |
| . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
FORM 12-A (Revised)
| Only for Unexempted Establishments Name and Address of the Estt. M/s . |
EMPLOYEES' PENSION SCHEME, 1995 [Paragraph 20(4)] Statement of contributions for the Month of |
(To be filled in by the EPFO) |
| Currency Period from 1st April, 200 to 31st March 200 |
Establishment Status |
| |
|
Group Code |
| Code No. Statutory rate of contribution |
|
| Particulars |
Wages on which Contri-butions are payable |
Amount of contribution |
Amount of contribution remitted |
Amount of Admini-strative charges due |
Amount of Admi-nistrative charges remitted |
Date of Remi-ttance (enclose triplicate copies of challan) |
| recovered from the workers |
payable by the employer |
Worker's share |
Emplo-yer's share |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
| 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 & address of the .. bank in which the amount is remitted. |
| |
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| (a) Contract (b) Rest (c) Total |
|
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| |
| Details of Subscribers |
E.P.F. |
Pension Fund |
E.D.L.I. |
| No. of Subscribers as per last month |
|
|
|
| No. of New Subscribers (vide Form 5) |
|
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| No. of Subscribers left service (vide Form 10) |
|
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| (Nett.) Total Number of Subscribers |
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|
Signature of the Employer
with Official Seal