Form 12-A(Revised)

Only for Un exempted Establishments

Name and Address of the Estt. M/s................................................ Cybrosys Techno Solutions Kinfra Neo Space............................... Malappuram................6789089.........

EMPLOYEES' PROVIDENT FUND AND MISC.PROVISIONS ACT,1952

EMPLOYEES' PENSION SCHEME [Paragraph 20(4)]

(To be filled in by EPFO)

Establishment status Group code

Currency period from 1st april,

2008

to 31st march , Jun / 2008 12.00 %

2009

Statement of contribution for the month of NE/AGT/0003455/123

Code No

Statutory rate of contribution Amount of Contribution 3 Recovered from Payable by the workers the employer 2,780 NIL NIL 897 1,623 112

Particulars 1 E.P.F A/c No.01 Pension Fund A/c No.10 E.D.L.I A/c No.21 total no.of employees (a) Contract (b) Rest (c) Total Details of subscribers 3

Wages on which Contributions are payable 2 22,500 22,500 22,500

Amount of contribution remitted Worker's share 2,780 Employer's share 897

Amount of Adminis trative charges due 5 248

Date of Amount of Adminis Remittance(enc trative charges remilose triplicate tted 6 248 01 Jun 2011 01 Jun 2011 01 Jun 2011

NIL NIL Name & address of the bank in which the amount is remitted

1,623 112 SBI. Ramanattukara.

NIL 3

NIL 3

E.P.F 3.00 0 0 3

Pension fund 3.00 0 0 3

E.D.L.I 3.00 0 0 3 Signature of the Employer with Official(Seal)

No.of subscribers as per last month No.of new subscribers (vide form 5) No. of subscribers left service(vide form 10) Totel number of subscribers