EMPLOYEES PROVIDENT FUNDS AND MISC.

PROVISIONS ACT, 1952 EMPLOYEES PENSION SCHEME [ PARA 20(4)]

Form 12 A ( R )

Only for Un-exempted Establishments Currency Period from 1st April 2 0 1 0 to 31st March, 2 0 1 1 ( To be filled by the EPFO)

Statement of Contribution for the month of 1 2 2 0 1 0 Dec-10 Group Code

Statutory Rate of Contribution 1 2 % Establishment Status

Name and Address of Establishment : M/s

Code No.: KN / BN / 31031

Amount of Contribution
Amount of Contribution
Remitted
Amount of
Amount of Date of remittance
Administrative
Wages on which Contributions are Payable Recovered Payable by Administrative (enclosed triplicate copies
Employee's Employer's Charges
from the the Charges Due of challan)
Share Share Remitted
Employees Employer

E P F A/c No. 01 103410.00 12409.00 3795.00 12409.00 3795.00 1138.00 1138.00

Pension Fund A/c. No. 10 103410.00 NIL 8614.00 NIL 8614.00 NIL NIL

E.D.L.I. A/c.No.21 103410.00 NIL 517.00 NIL 517.00 10.00 10.00

Total No. of Employees

Contract 0 Name & Address of the Bank in State Bank of India

Rest 28 which the amount is remitted

Total 28
Pension
Details of Subscribers E.P.F. E.D.L.I
Fund
No. of New Subscribers as per last month (vide F/12A) 27 27 27

No. of New Subscribers (vide from 5) 2 2 2 Signature of the Employer

No. of Subscribers left services (vide from 10) 1 1 1 with official ( Seal)

Nett Total Number of Subscribers 28 28 28

OYEES PENSION SCHEME [ PARA 20(4)]

( To be filled by the EPFO)

Date of remittance
(enclosed triplicate copies
of challan)

12409.00 12409.00 517.00 1138.00 10.00 26483.00

 Form - 5
THE EMPLOYEES PROVIDENT FUNDS SCHEME, 1952 (Paragraph 36 (2) (a) & EMPLOYEES PENSION SCHEME, 1995 (Paragraph 20 (2)

Returns of Employees qualifying for membership of the Employees Provident Fund, Employees Pension Fund & Employees Deposit Linked Insurance Fund
for the first time during the month of Dece - 2 0 1 0 (To be sent to the commissioner with Form 2 ( EPF & EPS)

Name and Address of the Factory / Establishment : M/s.

Code No of Factory / Establishment : KN /31031

Total period of
previous Services
Father's name or husband's as on the date of
Name of the employee Date of Date of joining
Sl No Account Number Name (in case of married Sex joining the fund Remarks
(in block letters) Birth the Fund
women) ( Enclose Scheme
certificate if
applicable)

01 41 #REF! Maralasiddappa 5/1/1980 M 12/1/2010

10/22/197
02 42 #REF! Rangaswamaiah M 12/1/2010
8
03
04
05
06
07
08

Signatures of the employer or other authorized officer

Date of the Factory / Establishment & Stamp of the Factory / Estt.
 Form - 10
THE EMPLOYEES PROVIDENT FUNDS SCHEME, 1952 (Paragraph 36 (a) & (b) EMPLOYEES PENSION SCHEME, 1995
(Paragraph 20 (2)

Returns of the members leaving services during the month of : DEC- 2010

Name and Address of the Factory / Establishment : M/s

Code No of Factory / Establishment : KN /

Father's name or husband's
Name of the employee Date of Leaving Reason for leaving
Sl No Account Number Name (in case of married Remarks
(in block letters) Services service
women)
1

Signature of the employer or other authorized officer

Date of the Factory / Establishment & Stamp of the Factory / Estt.

Please state whether the member is (a) retiring according to Para (69), (I) or (b) of the scheme (b) leaving India for permanent settlement abroad ( c )
retrenchment (d) Pt. & total disablement due to employment injury (e) discharged (f) resigning from or leaving services (g) taking up employment
elsewhere (The name and address of the Employers should be stated ) (h) death : (I) attained the age of 58 years.
Certified that the member mentioned at serial No……….. Shri…………………………. Was paid / not paid retrenchment compensation of Rs…………….
Under the industrial Dispute Act.1947.
 COMBINED CHALLAN NO. 1, 2, 10, 21 & 22
ORIGINAL
STATE BANK OF INDIA

EMPLOYEES PROVIDENT FUND ORGANIZATION Jan-11

( USE SEPARATE CHALLAN FOR EACH MONTH )

ESTABLISHMENT CODE NO. KN / ACCOUNT GROUP NO PAID BY CHEQUE √ / CASH

M M Y Y Y Y D D M M Y Y Y

DUES FOR THE Employees Share 0 1 2 0 1 1

MONTH OF
DATE OF PAYMENT 0 2 2 0 1
Employer Share 0 2 2 0 1 1

Total No. of Subscribers 24 24 24

A/c. 1 A/c. 10 A/c. 21
Total Wages Due 100000.00 100000.00 100000.00
Sl A/C No. 1 A/C No. 2 A/C No. 10 A/C No. 21 A/C No. 22 TOTAL
PARTICULARS
No. AMOUNT ( IN RUPEES)

1 EMPLOYERS SHARE OF CONTRIBUTION 3670.00 8330.00 500.00 12500.00

2 EMPLOYEES SHARE OF CONTRIBUTION 12000.00 12000.00

3 ADMIN CHARGES 1100.00 10.00 1110.00

4 INSPECTION CHARGES

5 PENAL DAMAGES
6 MISC. PAYMENT
7 PAST ACCUMULATIONS

TOTAL 15670.00 1100.00 8330.00 500.00 10.00 25610.00

Amount in words Rs. Twenty Six Thousand Two hundred Eighty Eight Only
NAME OF THE ESTABLISHMENT : ( For Bank's Use Only )
Amount Received Rs.
ADDRESS : For Cheque only
Date of Presentation
NAME OF THE DEPOSITOR Date of Realization
SIGNATURE OF THE DEPOSITOR Branch Name
( TO BE FILLED IN BY EMPLOYERS ) Branch Code No.
NAME OF THE BANK CHEQUE NO. DATE
 COMBINED CHALLAN NO. 1, 2, 10, 21 & 22
DUPLICATE
STATE BANK OF INDIA

EMPLOYEES PROVIDENT FUND ORGANIZATION Jan-11

( USE SEPARATE CHALLAN FOR EACH MONTH )
ESTABLISHMENT CODE NO. KN0/ ACCOUNT GROUP NO PAID BY CHEQUE √ / CASH

M M Y Y Y Y D D M M Y Y Y

DUES FOR THE Employees Share 0 1 2 0 1 1

MONTH OF
DATE OF PAYMENT 0 2 2 0 1
Employer Share 0 1 2 0 1 1

Total No. of Subscribers 24 24 24

A/c. 1 A/c. 10 A/c. 21
Total Wages Due 100000.00 100000.00 100000.00
Sl A/C No. 1 A/C No. 2 A/C No. 10 A/C No. 21 A/C No. 22 TOTAL
PARTICULARS
No. AMOUNT ( IN RUPEES)

1 EMPLOYERS SHARE OF CONTRIBUTION 3670.00 8330.00 500.00 12500.00

2 EMPLOYEES SHARE OF CONTRIBUTION 12000.00 12000.00

3 ADMIN CHARGES 1100.00 10.00 1110.00

4 INSPECTION CHARGES

5 PENAL DAMAGES

6 MISC. PAYMENT

7 PAST ACCUMULATIONS

TOTAL 15670.00 1100.00 8330.00 500.00 10.00 25610.00

Amount in words Rs. Twenty Six Thousand Two hundred Eighty Eight Only
NAME OF THE ESTABLISHMENT : ( For Bank's Use Only )
Amount Received Rs.
ADDRESS : For Cheque only
Date of Presentation
NAME OF THE DEPOSITOR Date of Realization
SIGNATURE OF THE DEPOSITOR Branch Name
( TO BE FILLED IN BY EMPLOYERS ) Branch Code No.
NAME OF THE BANK CHEQUE NO. DATE
COMBINED CHALLAN NO. 1, 2, 10, 21 & 22
TRIPLICATE
STATE BANK OF INDIA

EMPLOYEES PROVIDENT FUND ORGANIZATION Jan-11

( USE SEPARATE CHALLAN FOR EACH MONTH )

ESTABLISHMENT CODE NO. KN0/ ACCOUNT GROUP NO PAID BY CHEQUE √ / CASH

M M Y Y Y Y D D M M Y Y Y

DUES FOR THE Employees Share 0 1 2 0 1 1

MONTH OF
DATE OF PAYMENT 0 2 2 0 1
Employer Share 0 1 2 0 1 1

Total No. of Subscribers 24 24 24

A/c. 1 A/c. 10 A/c. 21
Total Wages Due 100000.00 100000.00 100000.00
Sl A/C No. 1 A/C No. 2 A/C No. 10 A/C No. 21 A/C No. 22 TOTAL
PARTICULARS
No. AMOUNT ( IN RUPEES)

1 EMPLOYERS SHARE OF CONTRIBUTION 3670.00 8330.00 500.00 12500.00

2 EMPLOYEES SHARE OF CONTRIBUTION 12000.00 12000.00

3 ADMIN CHARGES 1100.00 10.00 1110.00

4 INSPECTION CHARGES

5 PENAL DAMAGES

6 MISC. PAYMENT

7 PAST ACCUMULATIONS

TOTAL 15670.00 1100.00 8330.00 500.00 10.00 25610.00

Amount in words Rs. Twenty Six Thousand Two hundred Eighty Eight Only
NAME OF THE ESTABLISHMENT : ( For Bank's Use Only )
Amount Received Rs.
ADDRESS : For Cheque only
Date of Presentation
NAME OF THE DEPOSITOR Date of Realization
SIGNATURE OF THE DEPOSITOR Branch Name
 ( TO BE FILLED IN BY EMPLOYERS ) Branch Code No.
NAME OF THE BANK CHEQUE NO. DATE
COMBINED CHALLAN NO. 1, 2, 10, 21 & 22
QUADRUPLICATE
STATE BANK OF INDIA

EMPLOYEES PROVIDENT FUND ORGANIZATION Jan-11

( USE SEPARATE CHALLAN FOR EACH MONTH )

ESTABLISHMENT CODE NO. KN0/ ACCOUNT GROUP NO PAID BY CHEQUE √ / CASH

M M Y Y Y Y D D M M Y Y Y

DUES FOR THE Employees Share 0 1 2 0 1 1

MONTH OF
DATE OF PAYMENT 0 2 2 0 1
Employer Share 0 1 2 0 1 1

Total No. of Subscribers 24 24 24

A/c. 1 A/c. 10 A/c. 21
Total Wages Due 84305.00 77105.00 77105.00
Sl A/C No. 1 A/C No. 2 A/C No. 10 A/C No. 21 A/C No. 22 TOTAL
PARTICULARS
No. AMOUNT ( IN RUPEES)

1 EMPLOYERS SHARE OF CONTRIBUTION 3670.00 8330.00 500.00 12500.00

2 EMPLOYEES SHARE OF CONTRIBUTION 12000.00 12000.00

3 ADMIN CHARGES 1100.00 10.00 1110.00

4 INSPECTION CHARGES

5 PENAL DAMAGES

6 MISC. PAYMENT

7 PAST ACCUMULATIONS

TOTAL 15670.00 1100.00 8330.00 500.00 10.00 25610.00

Amount in words Rs. Twenty Six Thousand Two hundred Eighty Eight Only
NAME OF THE ESTABLISHMENT : ( For Bank's Use Only )
Amount Received Rs.
ADDRESS : For Cheque only
Date of Presentation
NAME OF THE DEPOSITOR Date of Realization
SIGNATURE OF THE DEPOSITOR Branch Name
( TO BE FILLED IN BY EMPLOYERS ) Branch Code No.
NAME OF THE BANK CHEQUE NO. DATE
ORIGINAL

Jan-11

4
00000.00

12500.00

12000.00

1110.00

25610.00

nly )
UPLICATE

Jan-11

4
00000.00

12500.00

12000.00

1110.00

25610.00

nly )
RIPLICATE

Jan-11

4
00000.00

12500.00

12000.00

1110.00

25610.00

nly )
ADRUPLICATE

Jan-11

4
77105.00

12500.00

12000.00

1110.00

25610.00

nly )