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Statement of Contributions for the currency period from

Statutory rate of contribution:%

1st................20........ to......................20......
Name and address of the Factory/Establishment........................

No. of members voluntarily subscribing at a higher rate: ...................

Code No. of the Factory/Establishment.....................................

S. No.

Account No.

Name of the member (in block capitals)

Wages, retaining allowance (if any) and D.A. including cash value of food concession paid during the currency period

Worker’s Contribution

Employer’s Contribution

Refund of advances

Rate of higher voluntary contribution (if any)

Remarks

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

Total

Rs.

Rs.

Rs.

Rs.

(Admn. Charges at 0.37% of wages)

Rs..........

Aggregate of (  )
Contributions. (  )

Cols. 5+6+7

Rs.

Sl. No.

Month

Amount Remitted contributions (including refund of advances)

Adm. Charges

Account No. 1

Account No. 2

Certified that the difference between the figures of total contribution and Adm. Charges remitted during the currency period and those shown under Cols. 4 to 7 above is solely due to the rounding off of the amounts to the nearest rupee/5 paise under the rules.

(1)           Total number of contribution cards enclosed (Form 3A).......
(2)           Certified that the Form 3A, duly completed, of all the members listed in this statement are enclosed, except those already sent during the course of the currency period for the final settlement of the concerned members’ accounts—vide ‘Remarks’ furnished against the names of the respective members above

1

Rs.

Rs.

2

Rs.

Rs.

3

Rs.

Rs.

4

Rs.

Rs.

5

Rs.

Rs.

6

Rs.

Rs.

7

Rs.

Rs.

8

Rs.

Rs.

9

Rs.

Rs.

10

Rs.

Rs.

11

Rs.

Rs.

12

Rs.

Rs.

Total

Rs.

Rs.

Signature of employer (with Office Seal).

Signature of employer

Notes :

(1)

The names of all the members, including those who had left service during the currency period, should be included in this statement. Where the Form 3A in respect of such members as had left service were already sent to the Regional Office for the purpose of final settlement of their account, the fact should be stated against the name of the member in the ‘Remarks’ column above thus: “Form 3A already sent in the month of ...........20......”.

(2)

In case of substantial variation in the wages/contributions of any member as compared to those shown in the previous statement, the reason should be explained adequately in the ‘Remarks’ column.