FORM 3A 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 1st............20..... to 30th/31st......20.... 1. Account No. ............................... 2. Name/Surname...................... 3. Father’s/Husband’s Name.......................... 4. Name & address of the Establishment.................... 5. Statutory rate of contribution.................... 6. Voluntary higher rate of employees’ contribution, if any.................... | Contributions | | Months | Amount of wages | Worker’s share | Employer’s share | Refund of Advances | Break in membership/ Reckonable service
From To | Remarks | EPF | EPF | Total | EPF | EPF | Total | 1 | 2 | 3 | 4 | 5 | 6 | 7 | | a | b | c | a | b | C | | April, 20 | May | June | July | August | September | October | November | December | January | February | March 20 | Total | | | | | | | | | | | | | | | | |
(a) Date of leaving service.................................................................................. (b) Reason for leaving service................................................................................................................................ (c) Certified that the total amount of contribution indicated in this card i.e. Rs................................ Col. (3)(c)........................................…………………………………………………………………………… Col. (4) (c) has already been remitted in full in EPF A/c No. 1 (P.F.A/c) and A/c No. 10(EPF contribution A/c) vide Note below: Certified that the difference between the total of the contributions shown under Cols. (3) and (4) of the above table and that arrived at on the total wages shown in Col. (2) at the prescribed rate is solely due to the rounding off of contributions to the nearest rupee under the rules. Dated...........20....... Signature of Employer (Office Seal) Note: In respect of the Form (3A) sent to the Regional Office during the course of the currency period for the purpose of final settlement of the accounts of the members who had left service details of date and reasons for leaving service, and also a certificate as shown in the “Remarks” columns should be added. | 
