The Employee's Provident Funds Scheme 1952 (Paragraph 43) Form 6-A (Revised)

AND
The Employee's Pensin Scheme 1995 (Paragraph 20 (4)) (For Un-exempted Establishment)

Annual Statement of contribution for the currency period from 1st April 2009 to 31st March 2010 Statutory rate of Contribution 12%

Name & Address of the Establishment: xxxxxxxxxxxxxxxxxxxxx No. of member voluntarily NIL
xxxxxxxxxxxxxxxxxx Cintributing at a higher rate:

Code No. of the Establishment GJ/14744-A

SR. Account Name of the Wages, rerai- Amount of Employer's Contribution Refund Rate of Remarks
NO. No. GJ/ Member ning allowances Workers EPF differ- Pension of higher
14744-A (in block letter) (if any) and contribution ence between Fund Advance voluntary
D A including deducted 10% & 8-1/3% 8-1/3% contribution
cash value of from the which ever is (if any)
food concession wages applicable as
paid during the the case may
currency period E.P.F. be
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
SR. Account Name of the Wages, rerai- Amount of Employer's Contribution Refund Rate of Remarks
NO. No. GJ/ Member ning allowances Workers EPF differ- Pension of higher
14744-A (in block letter) (if any) and contribution ence between Fund Advance voluntary
D A including deducted 10% & 8-1/3% 8-1/3% contribution
cash value of from the which ever is (if any)
food concession wages applicable as
paid during the the case may
currency period E.P.F. be
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
SR. Account Name of the Wages, rerai- Amount of Employer's Contribution Refund Rate of Remarks
NO. No. GJ/ Member ning allowances Workers EPF differ- Pension of higher
14744-A (in block letter) (if any) and contribution ence between Fund Advance voluntary
D A including deducted 10% & 8-1/3% 8-1/3% contribution
cash value of from the which ever is (if any)
food concession wages applicable as
paid during the the case may
currency period E.P.F. be
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
96
97
98
99
100
101
102
103
104
105
106
TOTAL 0.00 0 0 0
No. MONTH Amount due
EPF Cont- Pension EDLI Adm. EDLI
ributions Fund Contri- Charges Adm. Date of
including Contribu- bution Account Charges Remittance
refund of tions A/c. No.2 0.01%
Advances A/c No.10 No.21
A/c. No.1
Rs. Rs. Rs. Rs. Rs.
( I ) Total number of contribution cards
1 March 10678 5688 342 751 7 12.04.2005
enclosed (Form 3-A (Revised) 54
2 April 11951 6351 381 839 8 13.05.2005
( ii ) Certified that forms 3/A duly
3 May 14629 7781 467 1027 10 13.06.2005 completed, of all the members listed
in this statement are enclosed except
4 June 16095 8545 514 1129 11 12.07.2005 those already sent during the course
of the currency period for the final
5 July 17808 9470 568 1250 12 12.08.2005 settlement of the concerned members
account vide Remarks furnished
6 August 16960 9014 541 1190 11 12.09.2005 against the names of the respective
members above.
7 September 15568 8278 497 1093 10 13.10.2005
For xxxxxxxxxxxxxxxxxxxxxxx
8 October 16544 8810 529 1163 11 15.11.2005

9 November 14279 7609 456 1003 10 12.12.2005

AUTHORISED SIGNATORY
10 December 16016 8524 511 1125 11 12.01.2006
Signature of employer or authorised
11 January 16639 8857 532 1170 11 13.02.2006 officer with official stamp of designation
and establishment.
12 February 14224 7588 455 1000 10 11.03.2006

Toral 181391 96515 5793 12740 122

To be agree
with total
F-6 (A)

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 3-A in respect of such member 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 Remark's column above thus Form 3-A already sent in the month of 19

(2) In case of substantial variation in the wages/contributions of any members as compared to those shown in
previous months statement the reason should be explained adequate in the `Remarks' column.

(3) In respect of those members who have not opted for Pension Fund their entire employers contribution
@ 8-1/3% or 10% or 12% as the case may be shown under column No. 6.