COMBINED ANNUAL RETURN : FORM - 20

( See Rule 134 (1))

Year Ending:
Factory License No.
i) Form 20Rule 134 Karnataka Factories Rules 1969
ii) Form XXV
Rules 82 (2) Central Labour ( Regulation & Abolition) Karnataka Rules. 1974
iii) Form IIIRule 22 (4) Karnataka Minimum Wages Rules, 1958
iv) Form DRule 20 Payment of Bonus Rules, 1975
v) Form IVRule 20 Karnataka Payment of Wages Rules 1963
vi) Form K,L,M,
Rule 16 Karnataka Maternity Benefit Rules, 1963
1. Name of the Factory / Establishment :
2. Full Postal Address
Location Address Telephone Fax Email

1) Factory

2) Registered / Head Office

3. Name and Residential Address of the Person / Principal Employer Responsible for Conduct and Control of the Business

Name Designation Residential Adress Telephone Mobile Email

4. Name and Residential Address of the Occupier and Manager

Sl No Name Designation Residential Adress Telephone Mobile Email

i)

[O]
ii) [R]
[F]
5. Date of Commencement of Manufacturing Business: 08.10.1991
6. Nature / Type of Industry / Establishment : Manufacturers of Bag Filters, Basket Strainers, Airfilters
7. Particulars of Products Manufactured / Services Rendered :
Name of the Product / Quantity
Sl No Annual Installed Capacity Percentage Achieved Value
Services Manufactured
I)
ii)
iii)
iv)

8. Does the factory carry on Hazardous Process under Section 2 (CB) of Factories Act, 1948 : / NO
If Yes
i) Wheather Health & Safety Policy prepared and published : / NO
ii) Wheather Occupational Health Center provided : / NO
iii) Whether Medical Officer appointed : / NO
iv) Whether Ambulance Van provided : / NO

9.a) Particulars of Employment

No. of man hours
No. of Persons No. Of Man days Worked Total Amount of Salary /
No of Persons On Rolls as on No. of Days Factory Worked including
On Rolls as on during The year Wages paid including OT
01.01.2009 Worked. O.T. during The year
31.12.2009 Men/Women/Total Wages and Allowances
Men/Women Total

b) Average Number of employments During the Year -

Men Women Total

c) Number of Employees Discharged, Dismissed, Terminated, Retenched, Resigned or Retired during the year :

10. Particulars of Earned Leave with Wages :

Total No. No. of

No. of Employees Number of Employees Discharged,
Of Employees No of Employees paid Wages/ Salary in
Availed / Granted Dismissed, Terminated, Retrenched,
Persons Eligible for lieu of Earned leave
Earned Leave Resigned of Retired during the year
Employed Earned leave
i) Men
ii) Women
11.a) Safety and Welfare Officers :
Number of Officers required To be appointed Number of Officers actually appointed
Safety Officers as per Sec. 40 B of
i) ….. …..
FactoriesOfficers
Welfare Act. as per Sec. 49 (1) of
ii) ….. …..
Factories Act.
b) Whether the following Welfare Measures are provided ?
i) Ambulance Room as per Section 45 (4) /
ii) Canteen as per Section 46 (1) /
iii) Whether the Canteen is run departmentally or through Contractor /
iv) Creche as per Section (1) /
v) Shelters , Rest Rooms and lunch Rooms as per Section 47 (1) /
12. Particulars of Accidents, Man'days Lost and others :
(I) Total number of accidents that have taken place in the year :
(II) Number of employees involved in such accidents :
(III) Total number of man'days lost in such accidents :
(IV) Number of employees returned to work after 48 hours of the accident ( Reportable accident )
a) Without permanent / Partial / total disblement :
b) With permanent / Partial / total disablement
v) Number of employees involved in accidents which either immediately or later within 7 days resulted in death:

13. Particulars of Maternity Beneifts :

Total No. of women workers who worked for a period of 160 days in the last 12 months immediately
1
preceding the date of delivery.
2 No. of Women workers discharged / dismissed in the last 12 months.
No. of women workers for whom pre-natal confinement and post-natal Confinement is provided by the
3
employer with free of cost.
4 No. of women workers died.
a) Before Delivery
b) After Delivery

Leave / Additional Leave details :

No. of women applied
Item Leave sanctioned Leave rejected
for leave
Miscarriage
Illness ( additional Leave under Sec. 10 )

Maternity Benefit paid : NA

Item No. of claims received No. of leaves sanctioned No. of claimes rejected Total benefit Paid in Rupees

Confinement
Micarriage
Illness
Medical Bonus

14. Particulars of Deductions made from salary ( Wages) NA

No. of Employees involved Total Amount of Deduction made
i) Fines
ii) Damages / Loss
iii) Brench of Contract
iv) Others
Total

15. Payment of Bonus paid during the year :

No. of employees Eligible For
Percentage of Bonus/ declared Total Amount of Bonus / paid Date of payment
Bonus
17 Nos.
16. Contract Labour :

Period of Max. No. of Contract Workmen

Names and Address No. of Persons
Contract Nature of Wrok Employed on Any Day during No. of Days Worked No. of Man'days Worked
of the Contractor Employed
From / to the year

Total 0 0
Certified that the information furnished above is, to the best of my knowledge and belief, correct.

Dated :
Place : Manager
Signature of Manager