(USE SEPARATE CHALLAN FOR EACH MONTH)

COMBINED CHALLAN OF A/C No.1,2,10,21 &22

Original / Duplicate
Triplicate / Quarduplicate

STATE BANK OF INDIA

EMPLOYEES' PROVIDENT FUND ORGANISATION
Establishment Code No.:

DL/CPM/31192

Employees Share

Account Group No._______________

M
0

M
3

Y
2

Y
0

Y
1

Y
2

Dues for the Month of

Date of Payment
Employer Share

PARTICULARS

Employer's Share of Contribution

1,725

Employee's Share of Contribution

5,640

A.D.M. Charges

Insp. Charges

Penal Damages

Misc. Payment (Past

Accumulation only)

D
3

M
0

M
4

Y
2

Y
0

Y
1

Y
2

2
A/c 10
9

A/c 21
9
47,000

47,000

3,915

235

5,875
5,640

517

526

Total
Amount in words

Name of Depositor

D
1

A/c No. 1
A/c No. 2
A/c No. 10
A/c No. 21
A/c No. 22
TOTAL
....AMOUNT (In Rupees)..

Name of Establishment
Address

A/c 1
9
47,000

Total No. of Subscribers

Total Wages Due

Sl. No.

Pay-Order

Paid by Cheque / Cash

7,365
517
3,915
235
9
12,041
_______________________________________________________________________________

PUFF INDIA PRIVATE LIMITED

(For Banks use only)

Amount Received Rs._______________________
For Cheques only_________________________
Date of presentation _______________________
Date of Realisation_________________________
Branch Name_____________________________
Branch Code No. __________________________

1877, OUTRAME LANE

KINGSWAY CAMP
NEW DELHI-110009
MR. SANJAY KHANNA

Signature of Depositor
_____________________________________
Name of the Bank
STATE BANK OF INDIA

Ch./P.O. No.

922501

Date:_____________________
4/13/2012