"FORM IV" Annual Return Wages and deductions from Wages.

Return for the year ending 31st December, 19. 1. (a) Name of the factory or establishment and postal address. (b) Industry . Number of days !or"ed during the year. 3. (a) Number of man#days !or"ed during the year.
$ersons recei%ing less than Rs. 1&&& (dults. )hildren * (b) (%erage daily number of persons employed during the year. $ersons recei%ing less than Rs. 1&&&. (dults. )hildren. $ersons recei%ing Rs.1&&& and more but less than Rs. 1'&&. $ersons recei%ing Rs. 1&&& and more but less than Rs. 1'&&.

(c) +ross amount paid as remuneration to persons getting less than Rs. 1&&& including deduction under section ,( ) ---------.. of !hich the amount due to profit sharing bonus is -----------and that sue to money %alue of concessions . is-------- -------(d) +ross amount paid as remuneration to persons getting Rs. 1&&& and more but less Rs. 1'&& including deductions under section ,( )--------------.. of !hich the amount due to profit sharing bonus is -------and that due to money %alue of concessions . is -----------.. /. 0otal !ages paid including deductions under section , ( ) on the follo!ing accounts, namely1 #

$ersons recei%ing less than Rs. 1&&&

$ersons recei%ing Rs. 1&&& and more but less Rs. 1'&&. (a) 2asic 3ages including o%ertime 3ages and non profit sharing bonus. (b) Dearness and other allo!ance in cash. (c) (rrears of pay in respect of pre%ious year or years paid during the year. 4. Number of cases and amount reali5ed as 1 # $ersons recei%ing less than Rs. 1&&& $ersons recei%ing Rs. 1&&& and more but less than Rs. 1'&&. No. of cases (mount No. of cases (mount. 1 3 / (a) 6ines. (b) Deductions for damage or loss. 17 Deductions for breach of contract. 3 / '. Disbursement from the fines fund. $urpose (a) (b) (c) (d) ,. 2alance of fines fund in hand at the end of the year. 8ignature-----------Designation-----------. (mount

X 0his is the aggregate number of attendance during the year. * 0he a%erage daily number person employed during the year is obtained by di%iding the aggregate number or attendance during the year by the number of !or"ing days. . 9oney %alue of concessions should be obtained by ta"ing the difference of the cost price paid by the employer and the actual price paid by the employees or supplies of essential commodities gi%en free or at concessional rates.: ; 0his from I< !as substituted by the +u=arat $ayment of 3ages ((mendment) Rules, 19'4 vide >. ? @.D. No. AB#8B#1 4CD$.3(#11'1#,&,/3#0, darted 14th Ectober, 19'4.