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Attendance Register cum Payroll 

2/17/2018 6:11

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Designed By Joshua.M
Form No. 25
(Prescribed Under Rule 103 of the Madras Factory Rules 1950 & under G.O. No. 2759 of 1959)

Register of Muster Roll for the Month of November-20

Date of Joining
FOR THE PERIOD ENDING DAYS

Basic + DA
Employee ID

Salary
Designation Nature of
S.No.

Name of the Worker Father s Name Work ESI Number EPF Number

Wednesday

Wednesday

Wednesday
Thursday

Thursday

Thursday
Saturday

Saturday

Saturday
Monday

Monday

Monday
Tuesday

Tuesday

Tuesday
Sunday

Sunday

Sunday

Sunday
Friday

Friday

Friday
Date Month Year

1 2 3 4 5 6 7 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22
X X
1 001 JOSHUA GOD MANAGER 12345678 5000.00 3000.00

2 002

3 003

4 004

5 005

6 006

7 007

8 008

9 009

10 010

11 011

12 012

13 013

14 014

15 015

16 016

17 017

18 018

19 019

TOTAL NO. OF EMPLOYEES 1

Page 2 of 35 Attendance Register (Worker's)


orm No. 25
as Factory Rules 1950 & under G.O. No. 2759 of 1959)

November-2009
Dated: 2/17/2018 6:11

No. of days counted


No. of days of leave
No. of days worked

No. of days absent

Other Allowance

Other Deduction
Bal Advance
FOR THE PERIOD ENDING DAYS

with wages

O.T Hours
for wages

Advance
P.T.

I.T.
Wednesday

Thursday

Saturday
Monday

Monday
Tuesday

Tuesday
Sunday
Friday
23 24 25 26 27 28 29 30 01 10 11 12 13 14 15 16 18 19 20 21 22 23 24 25
X X
4 0 0 4 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

Page 3 of 35 Attendance Register (Worker's)


Presc

Wages Min

Date of Joining

Minimum rate
Emp.ID

Name & Address of

Total Wages
S.No.

Conveyance
Basic+HRA

Allowance

Allowance
Basic + DA
Designation

of wages
Medical
the Employee

Salary

Total
HRA

HRA
1 001 JOSHUA MANAGER 5000.00 3000.00 1250.00 4250.00 750.00 500.00 5500.00 400.00 167.00

2 002 0.00 0.00 0.00 0.00 0.00 0.00 0.00

3 003 0.00 0.00 0.00 0.00 0.00 0.00 0.00

4 004 0.00 0.00 0.00 0.00 0.00 0.00 0.00

5 005 0.00 0.00 0.00 0.00 0.00 0.00 0.00

6 006 0.00 0.00 0.00 0.00 0.00 0.00 0.00

7 007 0.00 0.00 0.00 0.00 0.00 0.00 0.00

8 008 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Page 4 of 35 Register of Wages (Worker's)


Presc

Wages Min

Date of Joining

Minimum rate
Emp.ID

Name & Address of

Total Wages
S.No.

Conveyance
Basic+HRA

Allowance

Allowance
Basic + DA
Designation

of wages
Medical
the Employee

Salary

Total
HRA

HRA
9 009 0.00 0.00 0.00 0.00 0.00 0.00 0.00

10 010 0.00 0.00 0.00 0.00 0.00 0.00 0.00

11 011 0.00 0.00 0.00 0.00 0.00 0.00 0.00

12 012 0.00 0.00 0.00 0.00 0.00 0.00 0.00

13 013 0.00 0.00 0.00 0.00 0.00 0.00 0.00

14 014 0.00 0.00 0.00 0.00 0.00 0.00 0.00

15 015 0.00 0.00 0.00 0.00 0.00 0.00 0.00

16 016 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Page 5 of 35 Register of Wages (Worker's)


Presc

Wages Min

Date of Joining

Minimum rate
Emp.ID

Name & Address of

Total Wages
S.No.

Conveyance
Basic+HRA

Allowance

Allowance
Basic + DA
Designation

of wages
Medical
the Employee

Salary

Total
HRA

HRA
17 017 0.00 0.00 0.00 0.00 0.00 0.00 0.00

18 018 0.00 0.00 0.00 0.00 0.00 0.00 0.00

19 019 0.00 0.00 0.00 0.00 0.00 0.00 0.00

GRAND TOTAL 5000.00 3000.00 1250.00 4250.00 750.00 500.00 5500.00 400.00 167.00

Page 6 of 35 Register of Wages (Worker's)


Register of Wages for The Month of October 2009
Prescribed Under G. O. No. 3283 Dt. 26-8-53 And Under Payment of Wages Rules

Hours O.T. during the

Gross wages earned


No. of days worked
Minimum rate of Wages DEDUCTIONS FROM WAGES

No. of days absent

Busfare Earnings
Normal Earning

O.T. earning

Advance Loan
month
Total normal

Total Wages
Conveyance

deductions
Allowance

Allowance
Medical

Others
Wages

E.S.I E.P.F P.T. I.T.


1.75% 4.75%

567.00 100.00 67.00 734.00 4.0 0.0 0.0 734.00 0.00 241.00 88.00 238.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

Page 7 of 35 Register of Wages (Worker's)


Register of Wages for The Month of October 2009
Prescribed Under G. O. No. 3283 Dt. 26-8-53 And Under Payment of Wages Rules

Hours O.T. during the

Gross wages earned


No. of days worked
Minimum rate of Wages DEDUCTIONS FROM WAGES

No. of days absent

Busfare Earnings
Normal Earning

O.T. earning

Advance Loan
month
Total normal

Total Wages
Conveyance

deductions
Allowance

Allowance
Medical

Others
Wages

E.S.I E.P.F P.T. I.T.


1.75% 4.75%

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

Page 8 of 35 Register of Wages (Worker's)


Register of Wages for The Month of October 2009
Prescribed Under G. O. No. 3283 Dt. 26-8-53 And Under Payment of Wages Rules

Hours O.T. during the

Gross wages earned


No. of days worked
Minimum rate of Wages DEDUCTIONS FROM WAGES

No. of days absent

Busfare Earnings
Normal Earning

O.T. earning

Advance Loan
month
Total normal

Total Wages
Conveyance

deductions
Allowance

Allowance
Medical

Others
Wages

E.S.I E.P.F P.T. I.T.


1.75% 4.75%

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00 0.0 0.0 0.0 0.00 0.00 0.00 0.00 0.00

567.00 100.00 67.00 734.00 734.00 0.00 0.00 241.00 88.00 238.00 0.00 0.00 0.00 0.00

Page 9 of 35 Register of Wages (Worker's)


Dated: 17/02/2018 06:11

FROM WAGES
EMPLOYEER
CONTRIBUTION

Net Wages Paid

Advance Loan
EPF Number
ESI Number

Balance
Deduction Date & Signature
of Employees

E.E.P.F

E.E.S.I
Total

326.00 360.00 409.00 408.00 12345678

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

Page 10 of 35 Register of Wages (Worker's)


Dated: 17/02/2018 06:11

FROM WAGES
EMPLOYEER
CONTRIBUTION

Net Wages Paid

Advance Loan
EPF Number
ESI Number

Balance
Deduction Date & Signature
of Employees

E.E.P.F

E.E.S.I
Total

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

Page 11 of 35 Register of Wages (Worker's)


Dated: 17/02/2018 06:11

FROM WAGES
EMPLOYEER
CONTRIBUTION

Net Wages Paid

Advance Loan
EPF Number
ESI Number

Balance
Deduction Date & Signature
of Employees

E.E.P.F

E.E.S.I
Total

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

0.00 0.00 0.00 0.00

326.00 360.00 409.00 408.00

Page 12 of 35 Register of Wages (Worker's)


LOGO YOUR COMPANY NAME
ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx 5000.00
Emp No. Employee Name Designation Date of Joining
001 JOSHUA MANAGER
Father / Husband Name Salary Day O.T.Hours

GOD 7th 0.00


Balance Advance Recoverable Days Worked Days Absent Account Number
EPF: 12345678
4.00 0.00
ESI:
EARNINGS DEDUCTIONS
Earned Basic 400.00 EPF 88.00
Earned HRA 167.00 ESI 238.00
Earned Conv. Allowance 100.00 P.T
Earned Medical Allowance 67.00 I.T
O.T 0.00 Employee Advance
Other Deduction

734.00 326.00
Amount In Words: for YOUR COMPANY NAME,
Err:511
Net Salary: 408.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
002
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:
EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511
Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
003
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511
Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
004
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511
Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
005
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
006
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
007
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
008
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
009
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
010
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
011
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
012
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
013
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
014
Father / Husband Name Salary Day O.T.Hours
7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
015
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
016
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
017
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
018
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory

YOUR COMPANY NAME


ADDRESS 
Pay Slip Cum Time Card (Form No. ) For The Month Of October 2009 Agreed Salary
(Under Rule xxxx Of T.N. Factories Act xxxx ) Reg.No.xx/xxxx
Emp No. Employee Name Designation Date of Joining
019
Father / Husband Name Salary Day O.T.Hours

7th 0.00
Balance Advance Recoverable Days Worked Days Absent Account Number
EPF:
0.00 0.00
ESI:

EARNINGS DEDUCTIONS
Earned Basic 0.00 EPF 0.00
Earned HRA 0.00 ESI 0.00
Earned Conv. Allowance 0.00 P.T
Earned Medical Allowance 0.00 I.T
O.T 0.00 Employee Advance
Other Deduction

0.00 0.00
Amount In Words: for YOUR COMPANY NAME,
Err:511

Net Salary: 0.00 Authorised Signatory


YOUR COMPANY NAME
<<<<< Previous Next > Unlock Save
Form 5
EMPLOYEE'S STATE INSURANCE CORPORATION
RETURN OF CONTRIBUTIONS (Regulation 26)

Employer's Code No.


Name and Address of the Establishment: Name Of Branch Office

Receipt of R.C Acknowledged


Subject to verification

Particulars of the Principal Employer(s)

(a) Name
(b) Designation
(c) Residential Address

Contribution Period from to

I furnish below the details of the Employer's share of contribution in respect of the under mentioned insured persons. I hereby declare that the
return includes each and every employee, employed directly or through an immediate employer or in connection with the work of the factory /
establishment or any work connected with the administration of the factory / establishment or purchase of raw materials, sale or distribution of
finished products ect. To whom the ESI Act, 1948 applies, in the contribution period to which this return relates and that the contributions in
respect of employer's and employee's share have been correctly paid in accordance with the provisions of the Act and Regulations.

Employee's Share
Employer's Share
Total Contribution
Details of Challans:
Sl.No. Month Date of Challan Amount Name of the Bank & Branch

Total Amount Paid Rs. 0.00

Important Instructions: Information to be given in "Remarks Column (No. 9)"

(i) If any I.P. is appointed for the first time and / or leaves during the contribution period indicate "A………….(date) and / or "L………… (date)"
(ii) Please indicate Insurance Nos. In ascending order.
(iii) Figures in Columns 4, 5 & 6 shall be in respect of wage periods ended during the contribution period.
(iv) Invariably strike totals of Columns 4, 5 and 6 of the Return,
(v) No overwriting shall be made. Any corrections, if made, should be signed by the employer.
(vi) Every page of this Return should bear full signature and rubber stamp of the employer.
(vii) Daily wages in Column 7 of the return shall be calculated by dividing figures in Column 5 by figures in Column 4 to two decimal places.
For *CP ending 31st March, due date is 12th May
For CP ending 30th September, due date is 11th November
I declare that
(a) All the Records and Registers have been maintained as per provisions contained in ESI Act, Rules & Regulations framed therein.
(b) During the period of return…………………No. of Declaration forms have been submitted.
(c) During the above period……………………………….No. of TICs have been received.
(d) During the above period……………………………….No. of PICs have been received.
(e) During the above period……………………………….No. of PICs have been distributed amongst the eligible Ips.
(f) During the above period……………………………….accidents have been reported to the concerned Branch Office.
(g) During the above period……………………………….No. of employees directly employed by us have been covered and a total wages of Rs.
have been paid to such employees.
(h) During the above period………………………….No. of employees directly employed by us have not been covered and a total wages of Rs.
have been paid to such employees.
(i) During the above period………………………….No. of employees employed through immediate employer have been covered and a total wages
of Rs. have been paid to such employees.
(j) During the above period………………………….No. of employees employed through immediate employer have been covered and a total wages

Page 24 of 35
of Rs. have been paid to such employees.

Form 5

(k) Following components of wages have been taken into consideration for the purpose of payment of contribution.

(l) Following components of wages have been taken into consideration for the purpose of payment of contribution.
1 3 5
2 4
The above mentioned information is based on records and any information if found incorrect will render me liable for prosecutions unders
provisions of ESI Act and action for recovery of contribution due along-with inrerest and damages as per provision of the ESI Act.

Date: RANIPET Signature & Designation of the


Place: Employer (with Rubber Stamp)

CERTIFICATE BY CHARTED ACCOUNTANT


(To be submitted in case of employers employing 40 or more employees)
Certified that I have verified the above return from the Records & Registers of M/s.
and found it to be correct.

Signature & Seal of the Chartered Accountant with Membership No.

Page 25 of 35
Form-6
E. S. I ACT FORM NO. 6
REGISTER OF EMPLOYEE'S
(REGULATION No. 32)
Name and Address of the CONTRIBUTION PERIOD
Establishment
From Apr-09 To Sep-09

MONTH (Apr-08) MONTH (May-08) MONTH (Jun-08) MONTH (Jul-08) MONTH (Aug-08) MONTH (Sep-08)

contribution period Date


If appointed during the

contribution period for


Dept. and shif if any

Total amount wages


paid/payable in the
contribution period

Daily wage (26÷25)


Total No. of days in

contribution in the
No. of days for which

No. of days for which

No. of days for which

No. of days for which

No. of days for which


No. of days for which
wages paid/payable

wages paid/payable

wages paid/payable
wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

Total employees
Employees share of

Employees share of

Employees share of

Employees share of

Employees share of
Employees share of
of appointment
Insurance No.

paid/payable
which wages
Total amount of

Total amount of

Total amount of

Total amount of
Total amount of

Total amount of
Occupation

contribution

contribution

contribution

contribution
contribution

contribution

period
S. No.

NAME OF THE INSURED


PERSON

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.
1 12345678 JOSHUA MANAGER 4.00 400.00 238.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1754.00 31.00 26.00 2400.00 42.00 26.00 2400.00 42.00 75.00 6954.00 353.00 92.72
2 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1974.00 35.00 26.00 2700.00 48.00 26.00 2700.00 48.00 71.00 7374.00 131.00 103.86
3 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 20.00 1454.00 26.00 26.00 1890.00 34.00 26.00 1890.00 34.00 72.00 5234.00 94.00 72.69
4 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1059.00 0.00 23.00 1451.00 0.00 25.00 1577.00 0.00 65.00 4087.00 0.00 62.88
5 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1152.00 0.00 25.00 1601.00 0.00 23.50 1505.00 0.00 66.50 4258.00 0.00 64.03
6 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1142.00 0.00 20.00 1269.00 0.00 14.50 937.00 0.00 52.50 3348.00 0.00 63.77
7 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1173.00 0.00 24.00 1565.00 0.00 25.00 1629.00 0.00 67.00 4367.00 0.00 65.18
8 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1272.00 0.00 22.50 1505.00 0.00 9.00 602.00 0.00 50.50 3379.00 0.00 66.91
9 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1226.00 0.00 26.00 1770.00 0.00 22.00 1498.00 0.00 66.00 4494.00 0.00 68.09
10 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1345.00 24.00 24.00 1698.00 30.00 23.00 1672.00 30.00 66.00 4715.00 84.00 71.44
11 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 921.00 0.00 15.00 952.00 0.00 7.50 476.00 0.00 37.50 2349.00 0.00 62.64
12 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1163.00 0.00 8.00 517.00 0.00 5.50 356.00 0.00 31.50 2036.00 0.00 64.63
13 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1239.00 0.00 25.00 1629.00 0.00 25.50 1662.00 0.00 69.50 4530.00 0.00 65.18
14 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1138.00 0.00 22.50 1505.00 0.00 24.00 1606.00 0.00 63.50 4249.00 0.00 66.91
15 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1128.00 0.00 23.50 1559.00 0.00 24.00 1592.00 0.00 64.50 4279.00 0.00 66.34
16 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1239.00 0.00 22.00 1435.00 0.00 10.00 652.00 0.00 51.00 3326.00 0.00 65.22
17 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1162.00 0.00 26.00 1590.00 0.00 26.00 1590.00 0.00 71.00 4342.00 0.00 61.15
18 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 923.00 0.00 23.00 1433.00 0.00 25.00 1557.00 0.00 63.00 3913.00 0.00 62.11
19 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 615.00 0.00 18.00 1108.00 0.00 19.00 1170.00 0.00 47.00 2893.00 0.00 61.55
20 0 0 0 0.00 400.00 238.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 370.00 0.00 4.00 246.00 0.00 0.00 0.00 0.00 10.00 1016.00 238.00 101.60
21 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1337.00 24.00 5.00 352.00 7.00 0.00 0.00 0.00 24.00 1689.00 31.00 70.38
22 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 888.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 888.00 0.00 63.43
23 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1870.00 33.00 26.00 2700.00 48.00 26.00 2700.00 48.00 70.00 7270.00 129.00 103.86
24 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1236.00 22.00 26.00 1890.00 34.00 26.00 1890.00 34.00 69.00 5016.00 90.00 72.70
25 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1138.00 0.00 26.00 1740.00 0.00 23.00 1540.00 0.00 66.00 4418.00 0.00 66.94
26 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1120.00 20.00 24.00 1680.00 30.00 26.00 1820.00 32.00 66.00 4620.00 82.00 70.00
27 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1046.00 0.00 23.00 1415.00 0.00 25.50 1570.00 0.00 65.50 4031.00 0.00 61.54
28 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1046.00 0.00 23.00 1415.00 0.00 21.00 1292.00 0.00 61.00 3753.00 0.00 61.52
29 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1099.00 0.00 26.00 1680.00 0.00 26.00 1680.00 0.00 69.00 4459.00 0.00 64.62
30 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1099.00 0.00 25.00 1616.00 0.00 2.00 129.00 0.00 44.00 2844.00 0.00 64.64
31 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1108.00 0.00 23.00 1499.00 0.00 0.00 0.00 0.00 40.00 2607.00 0.00 65.18
32 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1205.00 0.00 22.00 1472.00 0.00 13.50 903.00 0.00 53.50 3580.00 0.00 66.92
33 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1034.00 0.00 20.00 1293.00 0.00 25.00 1616.00 0.00 61.00 3943.00 0.00 64.64
34 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1043.00 0.00 21.00 1369.00 0.00 23.00 1499.00 0.00 60.00 3911.00 0.00 65.18
35 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1046.00 0.00 22.00 1354.00 0.00 26.00 1600.00 0.00 65.00 4000.00 0.00 61.54
36 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 969.00 0.00 4.00 259.00 0.00 0.00 0.00 0.00 19.00 1228.00 0.00 64.63
37 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1006.00 0.00 25.00 1572.00 0.00 26.00 1635.00 0.00 67.00 4213.00 0.00 62.88
38 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1006.00 0.00 25.00 1572.00 0.00 26.00 1635.00 0.00 67.00 4213.00 0.00 62.88
39 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1070.00 0.00 24.00 1606.00 0.00 23.00 1540.00 0.00 63.00 4216.00 0.00 66.92
40 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.50 1085.00 19.00 18.00 1260.00 23.00 19.00 1330.00 24.00 52.50 3675.00 66.00 70.00
41 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 873.00 0.00 26.00 1620.00 0.00 23.00 1433.00 0.00 63.00 3926.00 0.00 62.32
42 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 795.00 0.00 26.00 1590.00 0.00 21.00 1284.00 0.00 60.00 3669.00 0.00 61.15
43 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 747.00 0.00 5.00 311.00 0.00 0.00 0.00 0.00 17.00 1058.00 0.00 62.24
44 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 969.00 0.00 26.00 1680.00 0.00 25.00 1616.00 0.00 66.00 4265.00 0.00 64.62
45 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 937.00 0.00 11.00 736.00 0.00 26.00 1740.00 0.00 51.00 3413.00 0.00 66.92
46 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.50 921.00 0.00 21.50 1365.00 0.00 22.00 1396.00 0.00 58.00 3682.00 0.00 63.48
47 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 888.00 0.00 16.50 1048.00 0.00 16.00 1015.00 0.00 46.50 2951.00 0.00 63.46
48 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 870.00 0.00 26.00 1740.00 0.00 26.00 1740.00 0.00 65.00 4350.00 0.00 66.92
49 0 0 0 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 810.00 0.00 5.00 311.00 0.00 0.00 0.00 0.00 18.00 1121.00 0.00 62.28
Rs. C/o…. 800.00 476.00 0.00 0.00 0.00 0.00 53710.00 234.00 67968.00 296.00 61674.00 292.00 184152.00 1298.00 3332.70
Form-6
E. S. I ACT FORM NO. 6
REGISTER OF EMPLOYEE'S
(REGULATION No. 32)
Name and Address of the CONTRIBUTION PERIOD
Establishment
From Apr-09 To Sep-09

MONTH (Apr-08) MONTH (May-08) MONTH (Jun-08) MONTH (Jul-08) MONTH (Aug-08) MONTH (Sep-08)

contribution period Date


If appointed during the

contribution period for


Dept. and shif if any

Total amount wages


paid/payable in the
contribution period

Daily wage (26÷25)


Total No. of days in

contribution in the
No. of days for which

No. of days for which

No. of days for which

No. of days for which

No. of days for which


No. of days for which
wages paid/payable

wages paid/payable

wages paid/payable
wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

Total employees
Employees share of

Employees share of

Employees share of

Employees share of

Employees share of
Employees share of
of appointment
Insurance No.

paid/payable
which wages
Total amount of

Total amount of

Total amount of

Total amount of
Total amount of

Total amount of
Occupation

contribution

contribution

contribution

contribution
contribution

contribution

period
S. No.

NAME OF THE INSURED


PERSON

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.
Rs. B/f… 800.00 476.00 0.00 0.00 0.00 0.00 53710.00 234.00 67968.00 296.00 61674.00 292.00 184152.00 1298.00 3332.70
50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 978.00 0.00 25.00 1745.00 0.00 22.00 1501.00 0.00 61.00 4224.00 0.00 69.25
51 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
52 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 885.00 0.00 12.50 851.00 0.00 0.00 0.00 0.00 25.50 1736.00 0.00 68.08
53 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 934.00 0.00 24.00 1496.00 0.00 26.00 1620.00 0.00 65.00 4050.00 0.00 62.31
54 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 943.00 0.00 23.00 1447.00 0.00 22.00 1384.00 0.00 60.00 3774.00 0.00 62.90
55 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 840.00 0.00 12.50 807.00 0.00 24.50 1583.00 0.00 50.00 3230.00 0.00 64.60
56 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 995.00 0.00 26.00 1725.00 0.00 25.00 1659.00 0.00 66.00 4379.00 0.00 66.35
57 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 954.00 0.00 21.00 1396.00 0.00 23.00 1565.00 0.00 58.00 3915.00 0.00 67.50
58 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 938.00 17.00 25.00 1803.00 32.00 25.00 1803.00 32.00 63.00 4544.00 81.00 72.13
59 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 945.00 0.00 26.00 1755.00 0.00 21.50 1451.00 0.00 61.50 4151.00 0.00 67.50
60 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 978.00 0.00 26.00 1695.00 0.00 26.00 1695.00 0.00 67.00 4368.00 0.00 65.19
61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 923.00 0.00 6.00 370.00 0.00 9.50 585.00 0.00 30.50 1878.00 0.00 61.57
62 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 11.00 677.00 0.00 24.00 1477.00 0.00 21.50 1323.00 0.00 56.50 3477.00 0.00 61.54
63 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 1137.00 20.00 26.00 1970.00 35.00 26.00 1970.00 35.00 67.00 5077.00 90.00 75.78
64 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 747.00 0.00 18.00 1121.00 0.00 23.00 1433.00 0.00 53.00 3301.00 0.00 62.28
65 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 870.00 0.00 24.00 1606.00 0.00 24.50 1640.00 0.00 61.50 4116.00 0.00 66.93
66 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 855.00 0.00 23.00 1513.00 0.00 25.00 1644.00 0.00 61.00 4012.00 0.00 65.77
67 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 11.00 723.00 0.00 25.00 1644.00 0.00 25.00 1644.00 0.00 61.00 4011.00 0.00 65.75
68 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 747.00 0.00 24.00 1496.00 0.00 24.00 1496.00 0.00 60.00 3739.00 0.00 62.32
69 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 805.00 0.00 20.50 1270.00 0.00 14.50 898.00 0.00 48.00 2973.00 0.00 61.94
70 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 768.00 0.00 23.00 1472.00 0.00 22.00 1409.00 0.00 57.00 3649.00 0.00 64.02
71 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 870.00 0.00 23.00 1540.00 0.00 25.00 1673.00 0.00 61.00 4083.00 0.00 66.93
72 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 870.00 0.00 24.00 1606.00 0.00 24.50 1640.00 0.00 61.50 4116.00 0.00 66.93
73 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.50 837.00 0.00 26.00 1740.00 0.00 25.00 1673.00 0.00 63.50 4250.00 0.00 66.93
74 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 803.00 0.00 25.50 1707.00 0.00 25.00 1673.00 0.00 62.50 4183.00 0.00 66.93
75 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 805.00 0.00 21.00 1300.00 0.00 18.00 1115.00 0.00 52.00 3220.00 0.00 61.92
76 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 848.00 0.00 25.00 1629.00 0.00 24.00 1565.00 0.00 62.00 4042.00 0.00 65.19
77 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 818.00 0.00 25.00 1572.00 0.00 24.50 1541.00 0.00 62.50 3931.00 0.00 62.90
78 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 837.00 0.00 25.00 1745.00 0.00 24.00 1676.00 0.00 61.00 4258.00 0.00 69.80
79 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 863.00 0.00 24.00 1592.00 0.00 24.50 1625.00 0.00 61.50 4080.00 0.00 66.34
80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 865.00 16.00 26.00 1875.00 33.00 24.50 1786.00 32.00 62.50 4526.00 81.00 72.42
81 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 870.00 0.00 25.00 1673.00 0.00 25.00 1673.00 0.00 63.00 4216.00 0.00 66.92
82 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 803.00 0.00 24.50 1640.00 0.00 19.50 1305.00 0.00 56.00 3748.00 0.00 66.93
83 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 597.00 0.00 25.00 1659.00 0.00 21.50 1426.00 0.00 55.50 3682.00 0.00 66.34
84 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 800.00 0.00 25.00 1538.00 0.00 22.50 1385.00 0.00 60.50 3723.00 0.00 61.54
85 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 768.00 0.00 22.00 1409.00 0.00 26.00 1665.00 0.00 60.00 3842.00 0.00 64.03
86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 652.00 0.00 23.50 1532.00 0.00 24.00 1565.00 0.00 57.50 3749.00 0.00 65.20
87 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 738.00 0.00 22.00 1354.00 0.00 22.00 1354.00 0.00 56.00 3446.00 0.00 61.54
88 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 738.00 0.00 20.00 1230.00 0.00 23.00 1415.00 0.00 55.00 3383.00 0.00 61.51
89 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 664.00 0.00 24.00 1592.00 0.00 22.50 1493.00 0.00 56.50 3749.00 0.00 66.35
90 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 704.00 13.00 20.00 1408.00 25.00 19.00 1337.00 24.00 49.00 3449.00 62.00 70.39
91 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 433.00 8.00 24.00 1731.00 31.00 25.00 1823.00 32.00 55.00 3987.00 71.00 72.49
92 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 549.00 0.00 20.00 1373.00 0.00 19.00 1305.00 0.00 47.00 3227.00 0.00 68.66
93 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
94 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 489.00 0.00 19.00 1162.00 0.00 0.00 0.00 0.00 27.00 1651.00 0.00 61.15
95 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 615.00 0.00 22.00 1354.00 0.00 16.50 1015.00 0.00 48.50 2984.00 0.00 61.53
96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 615.00 0.00 26.00 1600.00 0.00 22.00 1354.00 0.00 58.00 3569.00 0.00 61.53
97 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 1350.00 24.00 26.00 2700.00 48.00 26.00 2700.00 48.00 65.00 6750.00 120.00 103.85
98 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 654.00 12.00 26.00 1890.00 34.00 26.00 1890.00 34.00 61.00 4434.00 80.00 72.69
Rs. C/o…. 800.00 476.00 0.00 0.00 0.00 0.00 91807.00 344.00 139778.00 534.00 130649.00 529.00 363034.00 1883.00 6465.32
Form-6
E. S. I ACT FORM NO. 6
REGISTER OF EMPLOYEE'S
(REGULATION No. 32)
Name and Address of the CONTRIBUTION PERIOD
Establishment
From Apr-09 To Sep-09

MONTH (Apr-08) MONTH (May-08) MONTH (Jun-08) MONTH (Jul-08) MONTH (Aug-08) MONTH (Sep-08)

contribution period Date


If appointed during the

contribution period for


Dept. and shif if any

Total amount wages


paid/payable in the
contribution period

Daily wage (26÷25)


Total No. of days in

contribution in the
No. of days for which

No. of days for which

No. of days for which

No. of days for which

No. of days for which


No. of days for which
wages paid/payable

wages paid/payable

wages paid/payable
wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

Total employees
Employees share of

Employees share of

Employees share of

Employees share of

Employees share of
Employees share of
of appointment
Insurance No.

paid/payable
which wages
Total amount of

Total amount of

Total amount of

Total amount of
Total amount of

Total amount of
Occupation

contribution

contribution

contribution

contribution
contribution

contribution

period
S. No.

NAME OF THE INSURED


PERSON

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.
Rs. B/f… 800.00 476.00 0.00 0.00 0.00 0.00 91807.00 344.00 139778.00 534.00 130649.00 529.00 363034.00 1883.00 6465.32
99 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 256.00 0.00 19.50 1249.00 0.00 25.00 1601.00 0.00 48.50 3106.00 0.00 64.04
100 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 561.00 0.00 25.00 1557.00 0.00 25.50 1589.00 0.00 59.50 3707.00 0.00 62.30
101 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 522.00 0.00 22.00 1435.00 0.00 9.00 587.00 0.00 39.00 2544.00 0.00 65.23
102 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 561.00 0.00 25.00 1557.00 0.00 26.00 1620.00 0.00 60.00 3738.00 0.00 62.30
103 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 587.00 0.00 25.00 1629.00 0.00 26.00 1695.00 0.00 60.00 3911.00 0.00 65.18
104 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 628.00 0.00 19.50 1362.00 0.00 0.00 0.00 0.00 28.50 1990.00 0.00 69.82
105 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 644.00 12.00 22.00 1574.00 28.00 21.00 1502.00 27.00 52.00 3720.00 67.00 71.54
106 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 572.00 11.00 22.00 1574.00 28.00 0.00 0.00 0.00 30.00 2146.00 39.00 71.53
107 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 613.00 0.00 24.00 1634.00 0.00 25.00 1701.00 0.00 58.00 3948.00 0.00 68.07
108 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 599.00 0.00 26.00 1730.00 0.00 25.00 1663.00 0.00 60.00 3992.00 0.00 66.53
109 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 587.00 0.00 26.00 1695.00 0.00 26.00 1695.00 0.00 61.00 3977.00 0.00 65.20
110 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 484.00 0.00 23.00 1592.00 0.00 20.00 1384.00 0.00 50.00 3460.00 0.00 69.20
111 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 587.00 0.00 23.00 1499.00 0.00 26.00 1695.00 0.00 58.00 3781.00 0.00 65.19
112 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 581.00 0.00 12.00 776.00 0.00 25.00 1616.00 0.00 46.00 2973.00 0.00 64.63
113 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 623.00 0.00 26.00 1800.00 0.00 24.50 1697.00 0.00 59.50 4120.00 0.00 69.24
114 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 551.00 0.00 24.00 1468.00 0.00 18.00 1101.00 0.00 51.00 3120.00 0.00 61.18
115 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 554.00 0.00 23.00 1415.00 0.00 21.00 1292.00 0.00 53.00 3261.00 0.00 61.53
116 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.50 467.00 9.00 26.00 1865.00 33.00 26.00 1890.00 34.00 58.50 4222.00 76.00 72.17
117 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 553.00 0.00 12.50 866.00 0.00 21.00 1453.00 0.00 41.50 2872.00 0.00 69.20
118 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 499.00 0.00 19.50 1215.00 0.00 20.50 1278.00 0.00 48.00 2992.00 0.00 62.33
119 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 453.00 0.00 14.00 904.00 0.00 23.00 1486.00 0.00 44.00 2843.00 0.00 64.61
120 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 492.00 0.00 16.00 985.00 0.00 11.00 677.00 0.00 35.00 2154.00 0.00 61.54
121 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 492.00 0.00 21.00 1292.00 0.00 0.00 0.00 0.00 29.00 1784.00 0.00 61.52
122 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 492.00 0.00 16.00 985.00 0.00 9.00 554.00 0.00 33.00 2031.00 0.00 61.55
123 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 492.00 0.00 8.50 523.00 0.00 0.00 0.00 0.00 16.50 1015.00 0.00 61.52
124 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 425.00 8.00 25.00 1770.00 31.00 25.00 1770.00 31.00 56.00 3965.00 70.00 70.80
125 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 352.00 7.00 21.00 1478.00 26.00 20.50 1443.00 26.00 46.50 3273.00 59.00 70.39
126 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 370.00 0.00 17.00 1046.00 0.00 0.00 0.00 0.00 23.00 1416.00 0.00 61.57
127 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 391.00 0.00 25.50 1662.00 0.00 8.00 522.00 0.00 39.50 2575.00 0.00 65.19
128 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 308.00 0.00 19.00 1170.00 0.00 19.00 1170.00 0.00 43.00 2648.00 0.00 61.58
129 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 288.00 6.00 22.00 1587.00 28.00 26.00 1875.00 33.00 52.00 3750.00 67.00 72.12
130 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 246.00 0.00 26.00 1600.00 0.00 20.00 1230.00 0.00 50.00 3076.00 0.00 61.52
131 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 246.00 0.00 20.00 1230.00 0.00 22.50 1385.00 0.00 46.50 2861.00 0.00 61.53
132 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 144.00 3.00 19.00 1371.00 24.00 0.00 0.00 0.00 21.00 1515.00 27.00 72.14
133 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 62.00 0.00 25.00 1538.00 0.00 26.00 1600.00 0.00 52.00 3200.00 0.00 61.54
134 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 26.00 3050.00 54.00 25.50 3050.00 54.00 51.50 6100.00 108.00 118.45
135 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 26.00 1610.00 0.00 25.00 1548.00 0.00 51.00 3158.00 0.00 61.92
136 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1088.00 0.00 22.00 1409.00 0.00 39.00 2497.00 0.00 64.03
137 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.00 1472.00 0.00 24.50 1640.00 0.00 46.50 3112.00 0.00 66.92
138 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25.00 1701.00 0.00 20.00 1362.00 0.00 45.00 3063.00 0.00 68.07
139 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 25.00 1731.00 0.00 26.00 1800.00 0.00 51.00 3531.00 0.00 69.24
140 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 24.50 1710.00 0.00 26.00 1815.00 0.00 50.50 3525.00 0.00 69.80
141 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.50 1480.00 0.00 7.00 460.00 0.00 29.50 1940.00 0.00 65.76
142 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 23.00 1513.00 0.00 21.50 1414.00 0.00 44.50 2927.00 0.00 65.78
143 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 23.00 1513.00 0.00 21.00 1381.00 0.00 44.00 2894.00 0.00 65.77
144 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.00 1472.00 0.00 9.00 602.00 0.00 31.00 2074.00 0.00 66.90
145 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 21.50 1521.00 27.00 5.00 354.00 7.00 26.50 1875.00 34.00 70.75
146 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 23.00 2388.00 42.00 23.00 2388.00 42.00 46.00 4776.00 84.00 103.83
147 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 747.00 0.00 23.00 1433.00 0.00 35.00 2180.00 0.00 62.29
Rs. C/o…. 800.00 476.00 0.00 0.00 0.00 0.00 108089.00 400.00 211407.00 855.00 192076.00 783.00 512372.00 2514.00 9780.36
Form-6
E. S. I ACT FORM NO. 6
REGISTER OF EMPLOYEE'S
(REGULATION No. 32)
Name and Address of the CONTRIBUTION PERIOD
Establishment
From Apr-09 To Sep-09

MONTH (Apr-08) MONTH (May-08) MONTH (Jun-08) MONTH (Jul-08) MONTH (Aug-08) MONTH (Sep-08)

contribution period Date


If appointed during the

contribution period for


Dept. and shif if any

Total amount wages


paid/payable in the
contribution period

Daily wage (26÷25)


Total No. of days in

contribution in the
No. of days for which

No. of days for which

No. of days for which

No. of days for which

No. of days for which


No. of days for which
wages paid/payable

wages paid/payable

wages paid/payable
wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

Total employees
Employees share of

Employees share of

Employees share of

Employees share of

Employees share of
Employees share of
of appointment
Insurance No.

paid/payable
which wages
Total amount of

Total amount of

Total amount of

Total amount of
Total amount of

Total amount of
Occupation

contribution

contribution

contribution

contribution
contribution

contribution

period
S. No.

NAME OF THE INSURED


PERSON

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.
Rs. B/f… 800.00 476.00 0.00 0.00 0.00 0.00 108089.00 400.00 211407.00 855.00 192076.00 783.00 512372.00 2514.00 9780.36
148 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 21.00 1345.00 0.00 20.50 1312.00 0.00 41.50 2657.00 0.00 64.02
149 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.00 1549.00 28.00 0.00 0.00 0.00 22.00 1549.00 28.00 70.41
150 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.00 1371.00 0.00 0.00 0.00 0.00 22.00 1371.00 0.00 62.32
151 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 20.00 1281.00 0.00 21.50 1377.00 0.00 41.50 2658.00 0.00 64.05
152 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 22.00 1536.00 0.00 22.00 1536.00 0.00 44.00 3072.00 0.00 69.82
153 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1205.00 0.00 23.00 1540.00 0.00 41.00 2745.00 0.00 66.95
154 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1128.00 0.00 24.50 1625.00 0.00 41.50 2753.00 0.00 66.34
155 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1064.00 0.00 7.50 499.00 0.00 23.50 1563.00 0.00 66.51
156 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.50 1037.00 0.00 21.50 1439.00 0.00 37.00 2476.00 0.00 66.92
157 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 1010.00 18.00 24.50 1767.00 31.00 38.50 2777.00 49.00 72.13
158 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1364.00 24.00 26.00 1970.00 35.00 44.00 3334.00 59.00 75.77
159 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1121.00 0.00 24.00 1496.00 0.00 42.00 2617.00 0.00 62.31
160 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1139.00 0.00 24.00 1519.00 0.00 42.00 2658.00 0.00 63.29
161 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 961.00 0.00 23.00 1472.00 0.00 38.00 2433.00 0.00 64.03
162 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1152.00 0.00 24.00 1537.00 0.00 42.00 2689.00 0.00 64.02
163 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 904.00 0.00 19.00 1227.00 0.00 33.00 2131.00 0.00 64.58
164 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1173.00 0.00 26.00 1695.00 0.00 44.00 2868.00 0.00 65.18
165 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 978.00 0.00 24.00 1565.00 0.00 39.00 2543.00 0.00 65.21
166 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1184.00 0.00 18.00 1184.00 0.00 36.00 2368.00 0.00 65.78
167 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1194.00 0.00 21.50 1426.00 0.00 39.50 2620.00 0.00 66.33
168 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 1004.00 0.00 23.50 1573.00 0.00 38.50 2577.00 0.00 66.94
169 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1157.00 0.00 20.00 1362.00 0.00 37.00 2519.00 0.00 68.08
170 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1226.00 0.00 23.50 1600.00 0.00 41.50 2826.00 0.00 68.10
171 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1196.00 21.00 21.50 1513.00 27.00 38.50 2709.00 48.00 70.36
172 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1154.00 21.00 19.00 1371.00 24.00 35.00 2525.00 45.00 72.14
173 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1298.00 23.00 24.00 1731.00 31.00 42.00 3029.00 54.00 72.12
174 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1154.00 21.00 24.00 1731.00 31.00 40.00 2885.00 52.00 72.13
175 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1177.00 0.00 26.00 1800.00 0.00 43.00 2977.00 0.00 69.23
176 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 897.00 0.00 24.00 1537.00 0.00 38.00 2434.00 0.00 64.05
177 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 782.00 0.00 22.00 1435.00 0.00 34.00 2217.00 0.00 65.21
178 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.50 822.00 0.00 19.00 1250.00 0.00 31.50 2072.00 0.00 65.78
179 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 928.00 0.00 9.00 597.00 0.00 23.00 1525.00 0.00 66.30
180 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 16.00 1070.00 0.00 22.50 1505.00 0.00 38.50 2575.00 0.00 66.88
181 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 747.00 0.00 14.00 873.00 0.00 26.00 1620.00 0.00 62.31
182 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00 964.00 0.00 23.00 1477.00 0.00 38.00 2441.00 0.00 64.24
183 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 870.00 0.00 22.00 1472.00 0.00 35.00 2342.00 0.00 66.91
184 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 652.00 0.00 25.00 1629.00 0.00 35.00 2281.00 0.00 65.17
185 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 721.00 13.00 19.50 1406.00 25.00 29.50 2127.00 38.00 72.10
186 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 831.00 0.00 26.00 1800.00 0.00 38.00 2631.00 0.00 69.24
187 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 831.00 0.00 25.00 1731.00 0.00 37.00 2562.00 0.00 69.24
188 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 1174.00 21.00 26.00 3050.00 54.00 36.00 4224.00 75.00 117.33
189 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1141.00 0.00 17.00 1141.00 0.00 67.12
190 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1187.00 0.00 18.00 1187.00 0.00 65.94
191 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1254.00 0.00 19.00 1254.00 0.00 66.00
192 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1187.00 0.00 18.00 1187.00 0.00 65.94
193 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1187.00 0.00 18.00 1187.00 0.00 65.94
194 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1187.00 0.00 18.00 1187.00 0.00 65.94
195 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1254.00 0.00 19.00 1254.00 0.00 66.00
196 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1187.00 0.00 18.00 1187.00 0.00 65.94
Rs. C/o…. 800.00 476.00 0.00 0.00 0.00 0.00 108089.00 400.00 255758.00 1045.00 260289.00 1041.00 624936.00 2962.00 13109.02
Form-6
E. S. I ACT FORM NO. 6
REGISTER OF EMPLOYEE'S
(REGULATION No. 32)
Name and Address of the CONTRIBUTION PERIOD
Establishment
From Apr-09 To Sep-09

MONTH (Apr-08) MONTH (May-08) MONTH (Jun-08) MONTH (Jul-08) MONTH (Aug-08) MONTH (Sep-08)

contribution period Date


If appointed during the

contribution period for


Dept. and shif if any

Total amount wages


paid/payable in the
contribution period

Daily wage (26÷25)


Total No. of days in

contribution in the
No. of days for which

No. of days for which

No. of days for which

No. of days for which

No. of days for which


No. of days for which
wages paid/payable

wages paid/payable

wages paid/payable
wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

wages paid/payable

Total employees
Employees share of

Employees share of

Employees share of

Employees share of

Employees share of
Employees share of
of appointment
Insurance No.

paid/payable
which wages
Total amount of

Total amount of

Total amount of

Total amount of
Total amount of

Total amount of
Occupation

contribution

contribution

contribution

contribution
contribution

contribution

period
S. No.

NAME OF THE INSURED


PERSON

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.
Rs. B/f… 800.00 476.00 0.00 0.00 0.00 0.00 108089.00 400.00 255758.00 1045.00 260289.00 1041.00 624936.00 2962.00 13109.02
197 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 17.00 1121.00 0.00 17.00 1121.00 0.00 65.94
198 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 1187.00 0.00 18.00 1187.00 0.00 65.94
199 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 13.00 858.00 0.00 13.00 858.00 0.00 66.00
200 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 19.00 1754.00 31.00 19.00 1754.00 31.00 92.32
201 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
202 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
203 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
204 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00
205
GRAND TOTAL Rs. 800.00 476.00 0.00 0.00 0.00 0.00 108089.00 400.00 255758.00 1045.00 265209.00 1072.00 629856.00 2993.00 13399.22
Form 12-A
FORM 12-A (Revised)
EMPLOYEES PROVIDENT FUND AND MISC. PROVISIONS ACT, 1952
EMPLOYEES PENSION SCHEME (PARAGRAPH 20 (4)]
Name and Address of the Estbalishment (To be filled by the EPFO)
M/s

Currency Period from 1st April, to 31st March Establishment Status

Statement of contribution for the Month of Group Code


Code No. TN/VL/
Statutory rate of contribution

Amount of Contribution due Amount of Contribution remitted


Wages on which Amount of Amount of
Particulars contributions are 3 4 Administrative charges Administrative charges Date of remittance (enclose triplicate
payable due remitted copies of Challan)
Recovered from Payable by the Worker's Share Employer's Share
the workers employer
1 2 5 6

E.P.F. A/c. No.01

Pension Fund A/c. No.10 NIL NIL NIL NIL

D.L.L.A. A/c. No.21 NIL NIL

Total No. of Employees

Contract Name & Address of the


bank in which the amount
Rest is remitted

Total

Details of Subsribers E.P.F Pension Fund E.D.L.I.

No. of Subscribers as per last month

No. of New Subscribers (Vide Form 5)

No. of Subscribers Lef Service (Vide Form 10)


Singature of the Employer
(Nett.) Total Number of Subscribers
with Official (Seal)
Form 12-A
FORM 12-A (Revised)
FUND AND MISC. PROVISIONS ACT, 1952
NSION SCHEME (PARAGRAPH 20 (4)]
(To be filled by the EPFO)

Date of remittance (enclose triplicate


copies of Challan)

Singature of the Employer


with Official (Seal)
YOUR COMPANY NAME
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