(COMBINED CHALLAN OF A/C NO.

1, 2, 10, 21 & 22) ORIGINAL

(USE SEPARATE CHALLAN FOR EACH MONTH) DUPLICATE

STATE BANK OF INDIA TRIPLICATE

QUADRUPLICATE

EMPLOYEES' PROVIDENT FUND ORGANISATION

Establishment Code No. : Account Group No. Paid by Cheque / Cash

MM YYYY DD - MM - YYYY

Employees Share Date of Payment

Dues for the month of :
Employer Share

Total No. of Subscribers `

A/c- 1 A/c- 10 A/c- 21

Total Wages Due

Sl. No. PARTICULARS A/c No. 1 A/c No. 2 A/c No. 10 A/c No. 21 A/c No. 22 Total
---------- AMOUNT ( In Rupees) ----------

1 Employer's Share of Cont. 0

2 Employees' Share of Cont. 0

3 ADM. Charges 0

4 Insp. Charges 0

5 Penal Damages 0

6 Misc. Payment (Past 0

Accumulations only)

TOTAL 0 0 0 0 0 0
-

Amount in words
(For Banks use only)
Name of Establishment Amount Received Rs.
Address For Cheques only
Date of Presentation
Date of Realisation
Name of Depositor Branch Name
Signature of the Depositor Branch Code No.

(TO BE FILLED IN BY EMPLOYER)

Name of the Bank Cheque no. Date