FORM 3 (For Unexempted Establishments only) THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 Paragraphs 35 and 42 AND THE EMPLOYEES’ FAMILY PENSION SCHEME, 1971 Paragraph 14 Contribution Card for the currency period from ..................to............ 1. Account No. 2. Name................................................... Surname............................... (In Block Capitals) 3. Father’s/Husband’s Name............................................................ 4. Name and address of establishment........................................ 5. Statutory rate of contribution.................................................... 6. Voluntary higher rate of employee’s contribution, if any........................................................ Contributions | Months | Member’s Share | Employer’s Share | Break in | Remarks | | E.P.F. | F.P.F. | Total | E.P.F. | F.P.F. | Total | Refund of advance Rs. P | Membership/ reckonable servicee From To | | @11/6% | @11/6% | Rs. | Rs. | Rs. | Rs. | Rs. | Rs. | April 20 | May | June | July | August | September | October | November | December | January | February | March 20 | Total |
Dated..............20.... Signature of the Employer (Office Seal) | 
