i

Attandance for the month of MAY 2008

THU FRI SAT SUN MON TUE WEN THU FRI SAT SUN MON TUE WEN THU FRI SAT SUN MON TUE WEN THU FRI SAT SUN MON TUE WEN THU FRI SAT
SL.No.
Name 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 29 30 31
### Days
1 P.SURESHCHANDRAN P P H P P P P P P H P P P P P P H P P P P P P H P P P P P P 26
2 V.SENTHILNATHAN P P H P P P P P P H P P P P P P H P P P P P P H P P P P P P 26
3 V.JAYAKUMAR P P H L L L P L L H P P P P P L H P P P L L L H P P P P P P 17
4 M.RAJASEAKARAN L L L H P P P P P P H P P P P P P H L L L P L L H L L P P P L 16
5 K.KANNAN P P H P P P L L L H P P P P L L H P P P P P P H P P L L P L 18
6 S.AMRUTHEEN A P P H P P P P P P H P P P P P P H P P P P P P H P P P P P P 26
7 K.JOTHI P P H L L L P P P H P P P L L L H P P P P P P H L L P P P L 16
8 VELLINGRI B P P H L L L L P L H P P P L P P H P L P P L L H P P P P P P 17
9 SIVA L L H P P P P P P H P L P L L L H P L P P P P H P L P L L L 15
10 A.VELU O P P H P L L P P L H P P P P P L H P L L P L P H P P L P P L 17
11 K.KARTHICK P P H P P P P L L H P P P P P L H P L L L P P H P L P P L L 17
12 P.GOVINDARAJ U P L H P P P P P P H P P P P P P H P L P P P P H P P L L L L 20
13 JAGANNATH L L H P P P L L L H P P P P L P H P P L P P L H P P P L L L 15
14 RAVI R P P H L L L P P P H P P P P L L H P P P P P L H P P P L L L 17
15 MANIVEL P P H P L P P P L H L L L L L L H P P P L P P H P P P P P L 16
16 RAMESH S P P H P P P P L L H P L L P P P H P L P P P L H P L P P L L 17
17 GANESH P L H L L P P P P H P L P P L L H P P P P P P H P P P P L P 19
18 STEAPAN D L L H P P P P P P H L L L P P L L P P P P P P H P L L L L L 15
19 SELVARAJ P P H P P P P P P H P P P P P L H P L P L L L H P P P O L L 18
20 SELVAM A P P H L P L P P P H P P P L L L H P P P P P P H P L L L P L 17
21 MURUGESAN P L H P P P P P P H P P L P P P H P L P L L L H P P P P P P 20
22 PRAKASH Y P P H L L L P P P H P P P L L L H P L P L L L H P P P P P P 16
23 DEBARAJ P L H P P P P L L H P P P P P P H L L L L P P H P P P P P P 19
24 SUDAY L P H L P P L L L H P P P L L L H P P P P P P H P L P P P P 17
25 RAMACHANDRAN H P P H P P P P P P H P P P P P P H L L L L L L H P P P P L L 18
26 GOBU O P P H L L L L L L H P P P P P L H P P P P L P H P P P L P P 17
27 MURUGAN L P P H P P P L L L H P L P P L L H P P P P P L H P L L L P P 16
28 RAJMOHAN I P P H P P P P P P H P P H P P P H L L P L P L H L P P P P L 19
29 PARAMASIVAM D P P H P P P P L L H P P P L P P H P P L P P L H P P H P L L 18
30 RAVI A P L H P L P P P P H L L L L L P H P P P P L P H P L P P L P 16
31 RAJU Y P P H P P H L L L H P P P L L L H P L P L L L H P P P P P P 15
32 SUNDARAJAN P P H P P P P P P H P P P P L L H P P P P P L H L L P P L L 19
33 PAVENDARAN P P H P P P L L L H P P P L L L H P L P P P P H P P L P P L 17
34 KARTHIKEYAN L L H P L P P L L H P L P P P P H P P P P P P H P L L L L L 15
35 SELVAM L L H P P P P P P H P P P P L L H P P L L L L H P P P P P P 18
 PAYROLL FOR THE MONTH OF MAY' 2008 STAFF YOUR COMPANY NAME

PF ESI RATE OF DAYS EARNED DEDUCTION NET PF P.F

A/C NOA/C NO WAGES WORKED WAGES ESI PF WAGES 3.67% 8.33%
S.NO NAME SALARY 1.75% 12% SALARY SIGANTURE

1 0 0 0 0 0 0 0

2 0 0 0 0 0 0 0

3 0 0 0 0 0 0 0

4 0 0 0 0 0 0 0

TTL TOTAL STAFF 0 0 0 0 0 0

OP 13
+ NIL 0
- NIL TOTAL 57969 6954 2122 4832
CL 13 G.TOTAL 57969 6954 A/C NO:1 2122 4832
4.75% 2122 A/C NO:1
TOTAL ESI 9076
TOTAL A/C NO:1
4832 A/C NO:10
638 A/C NO:2
290 A/C NO:21
6 A/C NO:22
TOTAL PF 14842

PAYROLL FOR THE MONTH OF MAY'08 WORKERS YOUR COMPANY NAME

 PF ESI RATE OF DAYS EARNED DEDUCTION NET PF P.F

A/C NOA/C NO WAGES WORKED WAGES ESI PF WAGES 3.67% 8.33%

S.NO NAME SALARY 1.75% 12% SALARY SIGANTURE

1 P.SURESHCHANDRAN 2300 26 2300 40 276 1984 84 192

2 V.SENTHILNATHAN 2900 26 2900 51 348 2501 106 242

3 V.JAYAKUMAR 2100 18 1454 25 174 1255 53 121

4 M.RAJASEAKARAN 2500 17 1635 29 196 1410 60 136

5 K.KANNAN 2500 19 1827 32 219 1576 67 152

6 S.AMRUTHEEN 3000 26 3000 53 360 2587 110 250

7 K.JOTHI 2100 17 1373 24 165 1184 51 114

8 VELLINGRI 2300 18 1592 28 191 1373 58 133

9 SIVA 2100 16 1292 23 155 1114 47 108

10 A.VELU 2200 18 1523 27 183 1313 56 127

11 K.KARTHICK 2300 18 1592 28 191 1373 58 133

12 P.GOVINDARAJ 2100 21 1696 30 204 1462 63 141

13 JAGANNATH 2300 16 1415 25 170 1220 52 118

14 RAVI 2300 18 1592 28 191 1373 58 133

15 MANIVEL 2200 17 1438 25 173 1240 53 120

16 RAMESH 2300 18 1592 28 191 1373 58 133

17 GANESH 2300 20 1769 31 212 1526 65 147

18 STEAPAN 2100 16 1292 23 155 1114 47 108

19 SELVARAJ 2300 19 1681 29 202 1450 62 140

20 SELVAM 2300 18 1592 28 191 1373 58 133

21 MURUGESAN 2300 21 1858 33 223 1602 68 155

22 PRAKASH 2300 17 1504 26 180 1298 55 125

23 DEBARAJ 2300 20 1769 31 212 1526 65 147

24 SUDAY 2300 18 1592 28 191 1373 58 133

25 RAMACHANDRAN 2000 19 1462 26 175 1261 53 122

26 GOBU 2100 18 1454 25 174 1255 53 121

27 MURUGAN 2200 17 1438 25 173 1240 53 120

28 RAJMOHAN 2200 20 1692 30 203 1459 62 141

29 PARAMASIVAM 2200 19 1608 28 193 1387 59 134

30 RAVI 2300 17 1504 26 180 1298 55 125

31 RAJU 2200 16 1354 24 162 1168 49 113

32 SUNDARAJAN 2200 20 1692 30 203 1459 62 141

33 PAVENDARAN 2200 18 1523 27 183 1313 56 127

34 KARTHIKEYAN 2200 16 1354 24 162 1168 49 113

35 SELVAM 2200 19 1608 28 193 1387 59 134

TTL TOTAL 57969 1018 6954 49997 2122 4832

OP - - - - - 35
+ ----- 0 GRAND TOTAL 57969 1018 6954 49997 2122 4832
--- - - - - - 0 4.75% 2759
CL - - - - - 35 TOTAL ESI 3777
 l
E. S. I. C. I E. S. I. C.
l
l
l
Challan No. l Challan No.
EMPLOYEES' STATE INSURANCE FUND ACCOUNT No.1 l EMPLOYEES' STATE INSURANCE FUND ACCOUNT No.1
PAY - IN - SLIP FOR CONTRIBUTION l PAY - IN - SLIP FOR CONTRIBUTION
STATE BANK OF INDIA l STATE BANK OF INDIA
Station Tirupur Date : l Station Tirupur Date :
Paid into the credit of the Employees' State Insurance l Paid into the credit of the Employees' State Insurance
Fund Account No. 1 Rs. 3777 l Fund Account No. 1 Rs. 3777
Rupees THREE THOUSAND SEVEN HUNDRED & SEVENTY SEVEN ONLY l Rupees THREE THOUSAND SEVEN HUNDRED & SEVENTY SEVEN ONLY
in cash / by Cheque (on realisation) for payment of contribution as per l in cash / by Cheque (on realisation) for payment of contribution as per
details given below under the Employees' State Insurance Act, 1948, l details given below under the Employees' State Insurance Act, 1948,
for the month of MAY'08 l for the month of MAY'08
l
Deposited by l Deposited by
l
Employer's Code No. l Employer's Code No. 0
l
Name and Address of Factory/Establishment l Name and Address of Factory/Establishment
YOUR COMPANY NAME l YOUR COMPANY NAME
ADDRESS ADDRESS
ADDRESS ADDRESS
No. Of Employees' 35 l No. Of Employees' 35
Total Wages Rs. 57969 l Total Wages Rs. 57969
Employees' Contribution Rs. 1018 l Employees' Contribution Rs. 1018
Employer's Contribution Rs. 2759 l Employer's Contribution Rs. 2759
Total Rs. 3777 l
l
Total Rs. 3777
(For use in Bank) l (For use in Bank)
ACKNOWLEDGEMENT l ACKNOWLEDGEMENT
(to be filled by depositor) l (to be filled by depositor)
Received payment with Cash / Cheque / Draft No. l Received payment with Cash / Cheque / Draft No.
dated for Rs. 3777 l dated for Rs. 3777
Rupees THREE THOUSAND SEVEN HUNDRED & SEVENTY SEVEN ONLY l Rupees THREE THOUSAND SEVEN HUNDRED & SEVENTY SEVEN ONLY
drawn on THE FEDERAL BANK LTD (Bank) in favour of l drawn on THE FEDERAL BANK LTD (Bank) in favour of
Employees' State Insurance Fund Account No. 1 _________________ l Employees' State Insurance Fund Account No. 1 _________________
Sl. No. In Bank's Scroll _______________________________________ l Sl. No. In Bank's Scroll _______________________________________
l
Dated: Authorised Signatory l Dated: Authorised Signatory
of the receiving Bank l of the receiving Bank
 COMBINED CHALLAN OF A/C. NO. 1,2,10,21 & 22
(STATE BANK OF INDIA)
EMPLOYEES' PROVIDENT FUND ORGANISATION
(USE SEPARATE CHALLAN FOR EACH MONTH)

ESTABLISHMENT CODE NO. ACCOUNT GROUP NO. PAID BY CHEQUE / CASH CHEQUE

D D M M Y Y

DUES FOR THE MONTH OF :

{ Employees Share

Employer Share
MAY'08
MAY'08
DATE OF PAYMENT

{ { {
Total no. of Subscribers 35 35 35
A/c . 1 A/c. 10 A/c.21
Total Wages Due 57969 57969 57969

S. 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) …………………..
PART - 01
1. EMPLOYER'S SHARE OF CONT. 2122 4832 290 7244

2. EMPLOYEES' SHARE OF CONT. 6954 6954

3. ADM. CHARGES 638 6 644

4. INSP. CHARGES

5. PENAL DAMAGES

6. MISC. PAYMENT

Total 9076 638 4832 290 6 14842

Amount in words FOURTEEN THOUSAND EIGHT HUNDRED & FOURY TWO ONLY
(For Banks use only)

NAME OF ESTABLISHMENT Amount Received Rs.

ADDRESS For Cheques only:
Date of presentation
NAME OF THE DEPOSITER Date of Realisation
SIGNATURE OF THE DEPOSITER Branch Name
(TO BE FILLED BY EMPLOYER) Branch Code No.
NAME OF BANK : CHQUE NO. DATE
NOTE : PLEASE ENSURE TOTAL OF EACH COLUMN AGREES WITH GRAND TOTAL
 FORM 12 - A (Revised)
Only for Un-Exempted Establishments (To be filled in by the EPFO)
Name and Address of the Estt. EMPLOYEES, PROVIDENT FUND AND MISC. PROVISIONS ACT, 1952
Establishment Status
YOUR COMPANY NAME EMPLOYEES' PENSION SCHEME (Paragraph 20 (4) )
ADDRESS Currency Period from 1 st April 200 8 To 31 st March 200 9

ADDRESS Statement of Contribution for the Month of A P R - 0 8 Group Code

Statutory rate of Contribution 1 2 %

Code No T N C B

Amount of Contribution Amount of Contribution remitted 4

3
Wages on which Amount of Amount of Date of Remittance
Particulars
Contribution Recovered Payable Worker's Employer's administrative administrative ( enclose triplicate copies
are payable from the by the Share Share Charges Due Charges remitted of challan)
1 2 workers Employer 5 6 7

E.P.F.A/c.No. 01 Rs 57969 6954 2122 6954 2122 638 638

Pension Fund A/c.No.10 Rs 57969 NIL 4832 NIL 4832 NIL NIL

E.D.L.I A/c.No. 21 Rs 57969 NIL 290 NIL 290 6 6

Total No.of Employees Name & address of the SBI

( a ) Contract -- --
( b ) Rest 35 Bank in Which the amount
( c ) Total 35 is remitted Rs. 14,842

Details of Subscribers E.P.F Pension fund E.D.L.I

No.of Subcribers as per last month 35 35 35
No.of New Subcribers (vide Form 5) 0 0 0
No.of Subcribers left service (vide Form 10) 0 0 0 Signature of the Employer
(Nett.) Total Number of Subcribers 35 35 35 with Official (Seal)
 FORM - 5 SRO CBE GR…………………………….
THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
[ Paragraph 36 ( 2 ) ( a ) ]
AND THE EMPLOYEES' PENSION SCHEME, 1995
[ Paragraph 20 ( 4 ) ]
Return of the employees qualifying for the Employees' Provident Fund, Emplyoees' Pension Fund & Employees' Deposit Linked Insurance Fund
for the first time during the month of MAY'08
(To be sent to the Commissioner with Form 2 ( EPF & EPS )
Name and Address of the Factory / Establishment YOUR COMPANY NAME
ADDRESS

Code No.of Factory / Establishment TN CB

Account Name of the Employee Father's Name ( or Husband's Name Date of Date of Total period of previous service
Sl.No No ( in block letters ) in case of married woman ) Birth Sex joining the as on the date joining the Fund Remarks
Fund (Enclose scheme Certificate if applicable)
1 2 3 4 5 6 7 8 9

Signature of the employer or other

Date: authorised officer of the Factory / Establishment
Stamp of the Factory / Establishment
 FORM - 10
THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 [ Paragraph 36 ( 2 ) ( A ) & ( B ) ]
AND THE EMPLOYEES' PENSION SCHEME, 1995 [ Paragraph 20 ( 2 ) ]
Return of the members leaving service during the month of
Name and Address of the Factory / Establishment YOUR COMPANY NAME Code No
ADDRESS
Account Name of the member Father's Name ( or Husband's Name Date of leaving Reasons for Leaving
Sl.No No ( in block letters ) in case of married woman ) Service Service Remarks

1 2 3 4 5 6 7

Signature of the employer or other authorised officer

Date Stamp of the Factory / Establishment

* Please state whether the member is (a) retiring according to para 69 (1) or (b)of the scheme: (b) leaving india for permanentsettement abroad: ( c ) retrenchment
(d) permanent & total disablement due to employment insury ; (e) discharged ; (f) resigning from or leaving service ; (g) taking up employment elsewhere ( The Name &
address of the Employers should be stated) (h) death (i) attained the age of 58 years.
"Certified that the member mentioned at serial No Shri / Smt / Kum was paid / not paid retrechment compenstion
of Rs: under the Industrial Dispute Act.1947

Signature of the Employer

 (For Unexempted Establishments only) (Form 3-A Revised)

THE EMPLOYEES' PROVIDENT FUND SCHEME, 1952

( Para 35 & 42 ) and
Emplyee's Pension Scheme, 1995
(Paras 19)

Contribution Card for the Currency Period From To

1. Account No. : 4. Name & Address

of the Establisment:

2. Name/Surname: #REF! 5. Statutory rate of contribution : 12%

3. Father's/husband Name: 6. Voluntary higher rate of employees contribution if any:

CONTRIBUTIONS * Refund Break in

Amount of Worker Share Employer's Share of membership
MONTH Remarks
Wages EPF Total EPF EPS Total Advances reckonable
a b a b c servive
1 2 3 4 5 6 7
Date of leaving serivce
Apr-03 #REF! #REF! #REF! #REF! #REF! #REF!

May-03
Reason for leaving service
Jun-03

Jul-03
Certified that the total amount of c
Aug-03
this card i.e Rs.
Sep-03
Col.3( b ) +col.4( c ) has already b
Oct-03
full in E.P.F. A/c No.1 (Provinde
Nov-03
Contributions A/c) and in Account
Dec-03
Pension Fund Contributions accou
Jan-04

Feb-04

Mar-04

TOTAL #REF!
Certified that the difference between the total of the contributions shown under the columns (3) & (4) of the above table and that
arrived at on the total wages shown in column (2) at the prescribed rate is solely due to the rounding off the contributions to be
nearest rupee under the rules.
* Contributions for the month of March paid in April

Date:
Signature of Employer
(Office Seal)

In respect of the Form ( 3A ) sent to the Regional Office during the course of the currency period for the purpose of final settlement
of the accounts of the members who had left service details of date and reasons for leaving service and also a certificate as shown
in the Remarks Column should be added
 NIL

marks

7
serivce

ing service

e total amount of contribution indicated in

#REF!
( c ) has already been remitted in

c No.1 (Provindent Fund.

/c) and in Account No.10(Employee's

Contributions account vide notebelow)

and that
ns to be

ployer
l)

tlement
shown
 1 P.SURESHCHANDRAN
2 V.SENTHILNATHAN
3 V.JAYAKUMAR
4 M.RAJASEAKARAN
5 K.KANNAN
6 S.AMRUTHEEN
7 K.JOTHI
8 VELLINGRI
9 SIVA
10 A.VELU
11 K.KARTHICK
12 P.GOVINDARAJ
13 JAGANNATH
14 RAVI
15 MANIVEL
16 RAMESH
17 GANESH
18 STEAPAN
19 SELVARAJ
20 SELVAM
21 MURUGAN
22 PRAKASH
23 DEBARAJ
24 SUDAY
25 RAMACHANDRAN
26 GOBU
27 MURUGAN
28 RAJMOHAN
29 PARAMASIVAM
30 RAVI
31 RAJU
32 SUNDARAJAN
33 PAVENDARAN
34 KARTHIKEYAN
35 SELVAM (REJOINED 1.4.2008)
36 SARTAR VALLABHAI PATTEL-LEFT 1.4.08

Date of Payment 04.06.2008

Deepthy Fenishers
Wages Period From : MAY'08

Workers Name : P.SURESHCHANDRAN

a. Min . Rate Wages of Payable : 2300

b. No of Days Working : 26

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 2,300

f. Deductions :
1.Advance : Nil
2.P.F : 276
3.ESIC : 40
Total 1,984

f. Actual wages paid for the period: : 1,984

Date Of Payment. : 04.06.2008

Signature of Worker Manager

Deepthy Fenishers

Wages Period From : MAY'08

Workers Name : V.SENTHILNATHAN

a. Min . Rate Wages of Payable : 2900

b. No of Days Working : 26

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 2,900

f. Deductions :
1.Advance : Nil
2.P.F : 348
3.ESIC : 51
Total 2,501

f. Actual wages paid for the period: : 2,501

Date Of Payment. : 04.06.2008

Signature of Worker Manager

Deepthy Fenishers

Wages Period From : MAY'08

Workers Name : V.JAYAKUMAR

a. Min . Rate Wages of Payable : 1454

b. No of Days Working : 18

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 1,454

f. Deductions :
1.Advance : Nil
2.P.F : 174
3.ESIC : 25
Total 1,255

f. Actual wages paid for the period: : 1,255

Date Of Payment. : 04.06.2008

Signature of Worker Manager

Deepthy Fenishers

Wages Period From : MAY'08

Workers Name : M.RAJASEAKARAN

a. Min . Rate Wages of Payable : 1635

b. No of Days Working : 17

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 1,635

f. Deductions :
1.Advance : Nil
2.P.F : 196
3.ESIC : 29
Total 1,410

f. Actual wages paid for the period: : 1,410

Date Of Payment. : 04.06.2008

Signature of Worker Manager

YOUR COMPANY NAME

Wages Period From : MAY'08

Workers Name : K.KANNAN

a. Min . Rate Wages of Payable : 1827

b. No of Days Working : 19

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 1,827

f. Deductions :
1.Advance : Nil
2.P.F : 219
3.ESIC : 32
Total 1,576

f. Actual wages paid for the period: : 1,576

Date Of Payment. : 04.06.2008

Signature of Worker Manager

YOUR COMPANY

Wages Period From : APR'08

Workers Name : S.AMRUTHEEN

a. Min . Rate Wages of Payable : 3000

b. No of Days Working : 26
c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 3,000

f. Deductions :
1.Advance : Nil
2.P.F : 360
3.ESIC : 53
Total 2,587

f. Actual wages paid for the period: : 2,587

Date Of Payment. : 03/05/2008

Signature of Worker Manager

YOUR COMPANY NAME

Wages Period From : APR'08

Workers Name : K.JOTHI

a. Min . Rate Wages of Payable : 1212

b. No of Days Working : 15

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 1,212

f. Deductions :
1.Advance : Nil
2.P.F : 145
3.ESIC : 21
Total 1,046

f. Actual wages paid for the period: : 1,046

Date Of Payment. : 03/05/2008

Signature of Worker Manager

YOUR COMPANY NAME

Wages Period From : APR'08

Workers Name : VELLINGRI

a. Min . Rate Wages of Payable : 1415

b. No of Days Working : 16

c. No of days working overtime : NIL

d. Allowance : NIL

e. The Gross Wages for the Wage period : 1,415

f. Deductions :
1.Advance : Nil
2.P.F : 170
3.ESIC : 25
Total 1,220

f. Actual wages paid for the period: : 1,220

Date Of Payment. : 03/05/2008

Signature of Worker Manager

YOUR COMPANY NAME

Wages Period From : APR'08

Workers Name : SIVA

a. Min . Rate Wages of Payable : 1292

b. No of Days Working : 16

c. No of days working overtime : NIL

d. Allowance : NIL
e. The Gross Wages for the Wage period : 1,292
f. Deductions :
1.Advance : Nil
2.P.F : 155
3.ESIC : 23
Total 1,114

f. Actual wages paid for the period: : 1,114

Date Of Payment. : 03/05/2008

Signature of Worker Manager
 FORM 6 - A
The Employees' Provident Fund Scheme, 1952
( Paragraph 43 ) and
The Employees' Pension Scheme, 1995
[ Paragraph 15 ( 4 ) ]

Annual statement of contribution for the Currency Period From 1st To

Name and address of the Estabilshment Statutory rate of contribution 12%

Code No. of the Establishment No.of member voluntary contributing at a higher rate Nos.

Wages retaining Employer's

allowance Amount of Workers Contribution Rate of
(if any) & Contributions Refund higher EDLI Remarks
S.No Account Name of member DA including deducted from of voluntary Contri-
Number ( in block letters ) Cash value of the wages PC Advance contribution bution
EPF Total
food concession 8.33% (if any)
paid during the EPF Total
currency period
1 2 3 4 5 6 7 8 9 10

TOTAL 0 0 0 0 0 0

P.T.O