Form 27 A Monthly Return [ See rule 119 (2) ]

Salary statement for the month ended This return is to be submitted by all factories electronically

General information
1 Name and address of factory, street, city, district Name and designation of owner /employer Name and designation of manager Contact details of employer Telephone e-mail 5 Contact details of manager Telephone e-mail 6 7 Unique Factory Number Registration number and its expiry date under Factoris Act Legal Status of establishment Registration Number Expiry Date Fax Mobile Fax Mobile

2 3 4

a.Proprietorship b.Partnership c.Private Limited Company d.Public Limited Company e.Cooperative Firm f.Family Business g.Other a. National b.Foreign c.Joint National and Foreign write down approriate type among the Schedule

Ownership

10

Type of employment as per the Schedule in the Minimum Wages Act, 1948 (Examplaes : Engineering, Loundry, Plastics etc.) Date of commencement of factory

11

Workforce Workers over Workers over 18 years 15 years but < 18 years Workers below15 years Total

M 12 13 14 15 Managers and supervisors (whose wage < 10,000) Number of permanent employees Contract workers Temporary workers Casual workers Badli workers Apprentices Trainees Family members Paid Unpaid

16

17

Name of the Factory .. Return for the month .towards the salary /wages of the each month of quarter paid to the employee Employee payment details to be submitted by employer every month Unique Employee Number (II)

Sr. No.

Name (I)

Gender (III)

Date of Payment (IV)

Bank Account No. (V)

Gross Wages (VI) Leave Maternity Over time encashment Benefit

Basic

DA

HRA

1 2 3 4 5 6

Other Payment (VII) Sr. No. Amount 1 Bonus Date Amount Gratuity Date Workmen Compensation Amount Date

Other Allowances

Total Payment (VIII) PF

Deduction (IX) ESI Tax Other

Recovery (X)

2 3 4 5 6

Gross Amount.. I verify and state that above information is true and correct to the best of my knowledge and belief.

Net Amount

Date
*employees' pension scheme, # employees' provident fund,@ employees deposit linked insurance scheme

Net Income (XI)

Employer Cont. EPF (XII)

Employer Cont. ESIC

*EPS 8.33%#EPF 3.67% @ EDLIS 0.5% (XIII)

mount..

Signature of owner/employer"