The Forms are available Free of cost

THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952

[Paragraph 43]
and

THE EMPLOYEES’ PENSION SCHEME, 1995

[Paragraph 20(4)]

Statutory rate contribution:

Annual Statement of Contribution Currency period from 1st ________ 20 to ______ 20 No. of member voluntarily
contributing at a higher rate:

Name & Address of the Establishment _______________________________________________________________________

_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Code No. of the Establishment: GJ/ _________________________________________________________________________

Sr. Account Name of the member in block Wages Amount of Employees’ Contribution Refund Rate of Remarks
No No. letter retaining workers EPF difference 1/3%
Fund 8 of higher
allowances contribution between 10% & 8 1/3%
adovance voluntary
(if any) deducted from & 12% & 81/3% contribution
and D.A. the wages Whichever is (if any)
including E.P.F. applicable as the
cash value case may be
of food
 concession
paid
during the
currency
period
1 2 3 4 5 6 7 8 9 10
Reconciliation of Remittance Total Rs. Rs. Rs. Rs.

Amount Remitted Adm. Charges Rs. Aggrigate Cols 5,6,7 Rs.

At 0.65% of wages Contribution ( )

No Month EPF Contribution Pension DLI Adm. EDLI Date of

including refund of fund Contribu Charges Adm. Remittance
Advances A/C No. 1 contribution tion A/C A/C No. Charges
Rs. A/C. No 10 No. 21 21 Rs. 0.01%
Rs. Rs. Rs.
1 March 1. Total number of
2 April contribution cards
3 May enclosed (Form 3A
4 June Revised)
5 July 2. Certified that form 3A
6 Aug duly completed. Of all
7 Sept the members listed in
8 Oct this statement are
9 Nov enclosed, except those
10 Dec already sent during
11 Jan the course of the
currency period for the
12 Feb
final settlement of the
Total
 concerned member’s
account vide ‘Remarks’
furnished against the
names of the
respective member
above.

Signature of Employer (With office seal.)

Note:
(i) The names of all members, including those who had left service during the currency period, should be include in this
statement, Where the Form 3-A in respect of such member had left service were already sent to the Regional Office
for the purpose of final settlement of their accounts, the fact should be stated against the members in the ‘Remarks’
column above thus 3-A already sent in the month of ________ 20 ___________
(ii) In case of substantial variation in the wages/contributions of any members as compared to those shown in previous
months statement, The reason should be explained adequate in the “Remarks” column
(iii) In respect of those members who have not opted for Pension Fund their entire employers contributions @ 8 1/3% or
10% or 12% as the case may be shown under column No.6