EMPLOYEES' STATE INSURANCE CORPORATION

Due Date for submission:- REG. FORM-5

Name of Branch Office: Employer's Code No.: 26000464740000799

RETURN OF CONTRIBUTIONS
(Regulation - 26)

Name & Address of the factory or establishment: SATYAM AUTO COMPONENTS LTD.
Particulars of the Principal employer(s) Machhiwara Road, Opp: Jashvir Oil Company
Kohara, Dist. - Ludhiana, Punjab.
a) Name
b) Designation
c) Residential Address

Contribution period from : April' 2010 To September' 2010.

I furnish below the details of the employer's and employee's share of contributions in respect of the under mentioned insured persons. I hereby
declare that the return includs each and every employee, employed directly or through an immediate employer or in connection with the work of
the factory/establishment or any work connected with the administration of the factory/establishment or purchase of raw materials, sale or
distribution of finished products etc. Tp whom the ESI Act, 1948 applies in the contribution period to which this return relates and that the
contributions in respect of employer's and employee's share have been correctly paid in accordance with the provisions of the act and regulations.

Employee's share
Employer's share
Total contribution 0.00

Details of Challans:
Sl. No. Month Date of Challan Amount Name of the Bank & Branch
1 April, 2010
2 May, 2010
3 June, 2010
4 July, 2010
5 August, 2010
6 September, 2010
Total Amount Paid: Rs.

Place Signature & Designation of the Employer

Date (With Rubber Stamp)

Important instructions: Information to be given in "Remarks Column (No. 9)"

If any I.P. is appointed for the first time and / or leaves during the contribution period indicate " A___________(date)" and/or
I "L______________ (date)".
II Please indicate insurance Nos. in assending order.

III Figures in Column 4, 5, & 6 shall be in respect of wage periods ended during the contribution period.
IV In variably strike totals of Column 4, 5, 6 of the return.
V No over righting shall be made. Any corrections, if made , should be signed by the employer.
VI Every page of this return should bear full signature and rubber stamp of the employer.
Daily wages in column 7 of the return shall be calculated by deviding figures in column 5 by figures in column 4 to two decimal places.
VII
For "CP ending 31st March due dates 12th May for "CP ending 30th September, due dates 11th November.

page 1
 EMPLOYEES' STATE INSURANCE CORPORATION

Employer's Name and Address: SATYAM AUTO COMPONENTS LTD.

Machhiwara Road, Opp: Jashvir Oil Company
Kohara, Dist. - Ludhiana, Punjab.
Employer's Code No.: 26000464740000799 Period from : April' 2010 To September' 2010.

No. of Employee' Whether

Total Average
days for s still
Sl. Amount of daily
Insurance No. Name of Insured Person which contributio continue Remarks
No. wages wages
wages n deducted s
paid (Rs.) (Rs.)
paid (Rs.) working

(1) (2) (3) (4) (5) (6) (7) (8) (9)

1
2
3
4
5

Date of appointment and leaving the job may be given in remarks column Signature of the Employer

(FOR OFFICIAL USE)

1 Entitlement position marked.

2 Total of column 5 of return checked and found correct / correct amount is indicated.
3 Checked the amount of employer's/employee's contribution paid which is in order/observation memo. Enclosed.

Counter Signature……………………………………..

U. D. C. Head Clerk Branch Officer

page 2
 EMPLOYEES' STATE INSURANCE CORPORATION

Due Date for submission:- REG. FORM-5

Name of Branch Office: Employer's Code No.: 26000464740000799

RETURN OF CONTRIBUTIONS
(Regulation - 26)

Name & Address of the factory or establishment: SATYAM AUTO COMPONENTS LTD.
Particulars of the Principal employer(s) Machhiwara Road, Opp: Jashvir Oil Company
Kohara, Dist. - Ludhiana, Punjab.
a) Name
b) Designation
c) Residential Address

Contribution period from : October, 2010' To March, 2011'.

I furnish below the details of the employer's and employee's share of contributions in respect of the under mentioned insured persons. I hereby
declare that the return includs each and every employee, employed directly or through an immediate employer or in connection with the work of
the factory/establishment or any work connected with the administration of the factory/establishment or purchase of raw materials, sale or
distribution of finished products etc. Tp whom the ESI Act, 1948 applies in the contribution period to which this return relates and that the
contributions in respect of employer's and employee's share have been correctly paid in accordance with the provisions of the act and
regulations.

Employee's share
Employer's share
Total contribution 0.00

Details of Challans:
Sl. No. Month Date of Challan Amount Name of the Bank & Branch
1 October, 2010
2 November, 2010
3 December, 2010
4 January, 2011
5 February, 2011
6 March, 2011
Total Amount Paid: Rs.

Place Signature & Designation of the Employer

Date (With Rubber Stamp)

Important instructions: Information to be given in "Remarks Column (No. 9)"

If any I.P. is appointed for the first time and / or leaves during the contribution period indicate " A___________(date)" and/or
I "L______________ (date)".
II Please indicate insurance Nos. in assending order.

III Figures in Column 4, 5, & 6 shall be in respect of wage periods ended during the contribution period.
IV In variably strike totals of Column 4, 5, 6 of the return.
V No over righting shall be made. Any corrections, if made , should be signed by the employer.
VI Every page of this return should bear full signature and rubber stamp of the employer.
Daily wages in column 7 of the return shall be calculated by deviding figures in column 5 by figures in column 4 to two decimal places.
VII
For "CP ending 31st March due dates 12th May for "CP ending 30th September, due dates 11th November.

Employer's Name and Address: SATYAM AUTO COMPONENTS LTD.

Machhiwara Road, Opp: Jashvir Oil Company
Kohara, Dist. - Ludhiana, Punjab.
Employer's Code No.: 26000464740000799 Period from : October, 2010' To March, 2011'.

No. of Employee' Whether

Total Average
days for s still
Sl. Amount of daily Remark
Insurance No. Name of Insured Person which contributio continue
No. wages wages s
wages n deducted s
paid (Rs.) (Rs.)
paid (Rs.) working

(1) (2) (3) (4) (5) (6) (7) (8) (9)

1 2607929112 Sandeep Kumar 182 50964.00 884.00 280.02
2 2608174398 Nagender Kumar 8 1657.00 29.00 207.13
3 2609112082 Avtar Singh 177 54957.00 965.00 310.49
4 2610175228 Seva Singh 20 4471.00 78.00 223.55
5 2610182013 Sajeev Kumar Pal 34 12350.00 216.00 363.24
6 Kapil 50.5 22438.00 394.00 444.32
7 2610482202 Pawan Kumar 41 12764.00 224.00 311.32
8 2610514292 Kulwinder Singh Saggu 28 9632.00 170.00 344.00
9 2610670850 Amrik Singh 23 2931.00 51.00 127.43
10 2611054000 Kishan Kumar 116 47224.00 826.00 407.10
11 2611054001 Lal Singh 90 33429.00 585.00 371.43
12 2611054002 Simarjeet singh 75.5 17313.00 304.00 229.31
13 2611054003 Ranbir Singh 70 26663.00 467.00 380.90
14 2611054004 Ashok Kumar 40 13082.00 229.00 327.05
15 2611054005 Jatinder Singh 31 13506.00 236.00 435.68
16 2611054006 Vishwajeet Singh 43 7499.00 131.00 174.40
17 2611054007 Kulwinder Singh Dhiman 29 3649.00 64.00 125.83
18 2611054008 Gajjan Singh 33 8057.00 141.00 244.15
19 Joginder Pal 8.5 2046.00 36.00 240.71
20 2611054009 Brijesh Kumar 6 695.00 13.00 115.83
21 2611054019 Hardeep Singh 34.5 5677.00 99.00 164.55
22 2611054020 Jagdish Singh 24.5 6728.00 118.00 274.61
23 2611054021 Bahadur Singh 19 3935.00 68.00 207.11
24 2611054022 Balwinder Singh 20 4471.00 78.00 223.55
25 2611054023 Tara Singh 18 2482.00 44.00 137.89
26 2611054024 Sher Shikander 14 4392.00 77.00 313.71
27 2611054025 Beant Singh 13 5066.00 89.00 389.69
1248.5 378078.00 6616.00

Date of appointment and leaving the job may be given in remarks column Signature of the Employer

(FOR OFFICIAL USE)

1 Entitlement position marked.
2 Total of column 5 of return checked and found correct / correct amount is indicated.
3 Checked the amount of employer's/employee's contribution paid which is in order/observation memo. Enclosed.

Counter Signature……………………………………..

U. D. C. Head Clerk Branch Officer