Form 2 Nomination

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					Date Of Appointment   :______________________

                                                        FORM 2 (REVISED)

 NOMINATION AND DECLARATION FORM                                                 Group No : ______
 FOR UNEXEMPTED / EXEMPTED ESTABLISHMENTS                                      Office : _____________


Declaration and Nomination Form under the Employees’ Provident Funds and Employees’ Pension Scheme
( Paragraph 33 and 61 (1) of the Employees’ Provident Fund Scheme, 1952 and Paragraph 18 of the Employees’ Pension
Scheme, 1995).

1. Name                           : __________________________ __________________________
( IN BLOCK LETTERS)                        FATHER’S/
2. Date of Birth______________________
3. PF Account No. MH / ______________ / __________
4. Sex : Male / Female :________________ 5.Marital Status : Married/ Unmarried/ Widow/Widower

6. Permanent address: ___________________________________________________________________________
        _____________________________________________________________________________________________

7.Temporary Address
_____________________________________________________________________________________________

                                              PART –A (EPF)
  I hereby nominate the person (s) / Cancel the nomination made by me previously and nominate the person(s), mentioned below to
               receive the amount standing to my credit in the Employees’ Provident Fund in the event of my death.

                                                                                                         If the nominee is
                                                                                                            minor, name
                                                                                     Total amount or
                                                                                                          relationship &
                                                                                         Share of
   Name & Address of the        Nominee’s relationship                                                     address of the
                                                                  Date of          accumulations in PF
       Nominee (s)                with the member                                                       guardian who may
                                                                                    to be paid to each
                                                                                                        receive the amount
                                                                                         nominee
                                                                                                       during the minority of
                                                                                                              nominee
                                                                   Birth
              -1                           -2                       -3                       -4                      -5




1.* Certified that I have no family as defined in para 2 (g) of the Employees’ Provident Funds Scheme,1952 and
should I acquire a family thereafter the above nomination should be deemed as cancelled.
2. * Certified that my father/ mother is/are dependent upon me.

(*) strike out whichever is not applicable.




                                                           X Signature or thumb impression of
            P. T.O.

                                                          PART –B (EPS)
                                                              (Para-18)
I hereby furnish below particulars of the members of my family who would be eligible to receive Widow / Children Pension in the event
of my death.

                                                                                                                Relationship with the
             Sr. No.                 Name and Address of the Family member/s                Date of Birth
                                                                                                                       member
               -1                                          -2                                     -3                     -4




                                  Certified that I have no
               **
                                  family, as defined para 2

I hereby nominate the following person for receiving the monthly widow pension [ admissible under para 16
(2) (i) & (ii) in the event of my death without leaving any eligible family member / s for receiving pension.

                                                                                                                   Relationship
               Sr.                         Name & Address of the Nominee                    Date of Birth
                                                                                                                   with member
               No.
               -1                                          -2                                     -3                     -4




Date :                                _____________
** Strike out which is not applicable


                                                                X Signature or thumb impression of the

                                                  CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed / thumb impressed before me by Shri/Smt/Miss
____________________________________________ employed in our establishment after he/she has read the entries have been read
over to him/her by me and got confirmed by him/her.

                                                                             FOR



                                                                             Authorised Signatory



Place                             :Mumbai

Date                              :_____________
                                                             Joint Declaration

To,
The Regional Provident Fund Commissioner,
Maharashtra
Mumbai.                                                                                                         Dated:_____________

Sub : Application for Regularisation of membership - Provident Fund Contribution deducted on salaries over and above Rs.6500/- or at higher ra
Sir,
I, the undersigned, Mr/Ms. ____________________________________bearing A/c. No. MH /_________/ ________ employee of M/s
___________________________________________________ hereby declare that I have been contributing Provident Fund on my entire
salary at the rate of 12 % w.e.f. ______________.
I am / am not an `excluded' employee within the meaning of para 2 (f) of the Employees' Provident Fund Scheme, 1952.
I request that :-
i)            I may be enrolled as member of the Employees' Fund voluntarily w.e.f. ________________
ii)           I may be permitted to contribute voluntarily on my entire salary exceeding Rs.6,500/- w.e.f. _____________
iii)          I may be permitted to contribute @ ______ % instead of the statutory rate of 12% w.e.f. ___________.

                                                                                                     Yours faithfully,



                                                                                                     Member's Signature.

We M/s ___________________________________________, bearing Code. No. MH / ______ hereby declare that :-
            We have voluntarily enrolled Mr/Ms ___________________________________________ as member of employees' Provident
i)          Fund w.e.f____________________ and his/her A/c. No. is MH / __________/________
ii)         We have been deducting contribution on his entire pay / up to Rs. ____________/- p.m. w.e.f. ____________
iii)        We have been making matching contribution on pay / up to Rs. ____________/- p.m. pay w.e.f. ___________
iv)         We have been deducting P.F. contribution voluntarily @12% of pay and making matching contribution @ 12% of pay.
            We have paid Administrative Charges and submitted all the returns in respect of the above member accordingly and will continue
v)          to do so.

We request that this case be regularised by permitting voluntary membership and contribution on entire salary of pay as stated above.

                                                                                                           Your faithfully,

                                                                                            For Doosan Project India Pvt. Ltd.

Place : MUMBAI

Date :
                                                                                                      Authorised Signatory
                                                        FORM 11 (REVISED)
                                               FOR UNEXEMPTED ESTABLISHMENTS ONLY.
                                            THE EMPLOYEES' PROVIDENT FUNDS SCHEME 1952
                                                          (Paragraph 34 ) and
                                             THE EMPLOYEE'S FAMILY PENSION SCHEME 1971.
                                                             (Paragraph 19)

Declaration by a person taking up employment in an establishment in which the Employee's Provident Fund and Family Pension Scheme
are in force.

I, Mr/Ms. ______________________________________________ son/daughter of
___________________________________________ do hereby solemnly declare that :

       (a)     I was last employed in
                                                               ( Name and full address of the establishment )
and left service on _______________________________________ (Prior of that) I was employed in _____________________
______________________________________________________ from ____________________ to _____________________.


(b)          I was a member of _________________________________________________________________________ Provident Fund

        and also / but not of the Family Pension Fund from __________________ to __________________ and my account number (s)
          was/were_______________________________________________________________________________________________.

       (c)     I have not drawn any superannuation benefits in respect of my past service from any employer.

       (d)     I have / have not withdrawn the amount of my provident fund/family pension fund.

(e)          I have never been a member of any Provident Fund and/or Family Pension Fund.

(f)          I am drawing / not drawing Pension under EPS, 1995.

(g)          I am holder / not holder of Scheme Certificate.

(h)          Scheme Certificate surrendered / not Surrendered.

                                                                                                                        X
       Date :___________________                                                                   Signature or right / left hand thumb impression of the



        _______________________________________________________________________________________________________________
(To be filled by the employer only when the person employed had not already been a member of the Employees' Provident Fund.)


Mr/Ms. ____________________________________________________ is appointed as
                                                                           (Designation)
in M/s. ________________________________________________________________________________________________________

 ________________________________________________________________ with effect from ____________________ ( Date of appointment )

Date of admission as member of Employees’ Pension Fund w.e.f. ____________________. Account No. MH /
                                                                                               For Doosan Project India Pvt. Ltd.



                                                                                                                                              Authorised
      Date: ______________________
                                                                                                                                 Signatory

Note: Strikeout which is not applicable.
N.B.: The principal employer should have it filled up also in respect of employee's to be employed by or through a contractor.
                                                          FORM 12-A (Revised)
                                                   [For unexempted establishments only]
                                      EMPLOYEES PROVIDENT FUNDS and Miscellaneous Provisions ACT, 1952
                                                     EMPLOYEES' PENSION SCHEME
                                                              [Para 20(4)]
Name and address of the establishment M/s ………………………….………………………………………………….[ To be filled in by the EPFO]
Currency Period from 1st April, 200………….... To 31st March 200 ……….... Establishment Status…………..……
Statement of contributions for the Month of ……………………………...…………….. Group Code ……………..………..
Code No. ……………………..……………………….. Statutory rate of contribution

                                                                    Amount of Contribution                                             Date of
                                       Amount of Contribution                                                     Amount of
                  Wages on which                                          remitted             Amount of                             Remittance
                                                                                                                 Administrative
  Particulars     Contributions are    recovered                                             Administrative                          (enclose tri-
                                                    Payable by     Workers's    Employer's                         charges
                      payable           form the                                              charges due                         plicate copies of
                                                   the employer     share         share                            remitted
                                        workers                                                                                        challan
E.P.F. A/C No.
                                                                                                  Nil                  Nil
01
A/C No. 10                                Nil                         Nil
E.D.L.I A/C No.
                                          Nil                         Nil
21

                                                                  Name and address of the bank in which the amount is remitted
                                                                  …………………………………………………………………………………………………
Total No. of Employees …………………………………………
                                                                  …………………………………………………………………………………………………
                                                                  …………………………………………………………………………………
(a) Contract
(b) Rest
( c ) Total

Details of Subscribers                                                            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 left service (vide Form 10)
(Nett) Total Number of Subscribers

                                                                                                        Signature of the Employer with Official Seal
                                               FORM 6
                       [ Paragraph 20 of the Employees Pension Scheme, 1995]
     (For Exempted Establishment only) Total No. of Employees …………..(Contract Rest Total)
                Statement of Contribution for the month of ……………………….20
                                                  Total No. of Subscribers ………………………………
Name and Address of the Establishment …………………………………………………………………..
Currency period from 1st April, 20………………….. To 31st March, 20…………………………………
Code No. of the Establishment ………….. Statutory Rate of Contribution 8.33%....................................

                                                                            Date of          Name and
Total                                                 Amount of
        Wages on which           Amount of                                Remittance        Address of the
No. of                                               contribution
        contributions are      contribution due                       (Triplicate copy of   bank in which
Subscri                                            remitted in A/c.
            payable                 8.33%                              the challan to be      amount is
bers                                                   No. 10
                                                                           enclosed)           remitted
(1)               (2)                 (3)                 (4)                  (5)               (6)


No. of Sub. As per last month's return ……………………………………………………………………….
Add. No. of New Subscribers-vide Form 4 (PS) ……………………………………………………………
Less No. of Subscribers left service-vide Form 5(PS) …………………………………………………….

                                                                                 Signature of the Employer
                                                                                         (with official seal)

Net total :
(This should tally with the figures given in Col. 1)
Note :- (1) If there is any substantial variation between the wages and contribution shown above and
those and those shown in the last month's return, suitable explanation should be given in the 'Remarks"
Column.
(2) If any arrears of contributions or damages are included in the figures under Column 4 suitable
details indicating the circumstances, amount, No. of subscribers and the period involved should be
furnished in the 'Remarks' column or on the reverse.
Date :
                                                              FORM 5 (EPS)
                                                           [See Paragraph 20(2)]
                                              THE EMPLOYEES' PENSION SCHEME, 1995
                                                     (For Exempted Estblishment only)
  Return of Employees entitled for membership of the Employees' Pension Fund during the month of………………………..20…………………
Name and address of the Establishment…………………………………………………………………………………………………………………
Code No. of the Establishment ……………………………………………………………………………………………………………………

                                                     Father's Name or           Date of    Reason for leaving
Sl.                 Name of the employee (in
    Account No.                                  Husband's Name (in case of     leaving    service (See note             Remarks
No.                     block capitals)
                                                      married woman)            service      given below)
 1        2                     3                            4                     5                6                        7


                                                                                        Signature of the Employer Stamp of the
Date              Stamp of the Establishment
                                                                                        Establishment
Note :- An employee who has attained 58 years will cease to be a member of the scheme and entitled to receive the due benefit under the
Employees Pension Scheme, 1995.
                                                                FORM 4 (EPS)
                                                              [See Paragraph 20]
                                                THE EMPLOYEES' PENSION SCHEME, 1995
                                                       (For Exempted Estblishment only)
   Return of Employees entitled for membership of the Employees' Pension Fund during the month of …………………………..20…………………
Name and address of the Establishment ………………………………………………………………………………………………………………….
Code No. of the Establishment TN/ ………………………………………………………………………………………………………………………

                                               Father's Name or Husband's                                Remarks, Previous Account
Sl.             Name of the employee (in block                            Age at     Date of entitlement
    Account No.                                Name (in case of married          Sex                     No. and particulars of
No.             capitals)                                                 entry      of membership
                                               woman)                                                    previous service, if any
 1       2                    3                             4                5    6          7                         8


                                                                                  Signature of the Employer or other authrorised officer of the
Date              Stamp of the Establishment
                                                                                  Establishment
Note :- An employee who has attained 58 years and/or for drawing Pension under the EPS-95 is not to be enrolled as a member.
                                                                                           FORM 12-A (Revised)
                                                                 (Paragraph 38(2) Proviso of the Employees Provident Funds Scheme, 1952)
                                     Statement of Contribution for the month of ……………………………………………….. 20 …………………………………………………..
Name and address of the establishment ………………………………………………………………………………………………………………………………………………
Code No. of the Establishment ……………………………………………………………………………………………………………………………………………….

                              Amount of contribution due as per
                                                                                Amount of contributions remitted in Amount of
                                   recoveries made in the                                                                          Amount
                                                                                    Account Nos. 1 and 10             Admn.
                                  wage/acquittance register                                                                            of                                        Whether the
              Wages on                                                                                               Charges                             Name and location of
                              Worker's Share   Employer's Share                 Worker's Share    Employer's Share due 0.37%        Admn.                                          triplicate
                which                                                                                                                                       the bank in which
Total No. of                                                                                                                        Charge Date of                              challan receipt
             contributions                                                                                            of the                           remitted or No. and date                      Remarks
subscribers                                                                                                                            s    remittance                          in enclosed, if
                  are          FPF 1           FPF 1                               FPF 1              FPF 1         amount of                          of the cheque/draft send
                           EPF       Total EPF       Total                    EPF          Total EPF          Total                remitted                                        not state
              recovered        1/6 %           1/6 %                               1/6 %              1/6 %           wages                                to Regional Officer
                                                                                                                                    in A/c.                                         reason
                                                                                                                    shown in
                                                                                                                                     No. 2
                                                                                                                    column 2
                             (a)    (b)   (c)    (a)    (b)   (c)              (a)   (b)    ( c ) (a)   (b)    (c)
     1              2                3                   4              5             6                  7      8        9           10         11                12                   13               14


1.   Total amount remitted in Account No. 1 Rs. ……………………….…………………………………………………………………………………
     Date of remittance ……………………………………………………………………………………………………………………………………
2. Total amount remitted in Account No. 1 Rs. ……………………….…………………………………………………………………………………
     Date of remittance ……………………………………………………………………………………………………………………………………
Account No. 1 ……………………………………………………………………………………………………………………………………………………………….
Account No. 10 ………………………………………………………………………………………………………………………………………………………………
Account No. 2 ………………………………………………………………………………………………………………………………………………….
No. as per last months return
(+) No. of New Subscribers - vide Form 5
(-) No. of New Subscribers left service - vide Form 10
* Net Total
This should tally with the figure given at the top right hand corner of this Form
                                                                                                                                                         Total No. of Employees ……………………………………..
                                                                                                                                                       Contract                    Rest
                                                                                                                                                       Total No. of Subscribers ……………………………………
Currency Period from 1st April, 200     to 31st March, 200
Statutory Rate of Contribution …………………………………………………………………….
No. of members voluntarily contributing at higher than the statutory rate ……………………………..

                                                                                                                                                                                        Signature of the Employer
                                                                                                                                                                                                (with official seal)
Date ……………………..
Notes :- (1) If there is any substantial variation between the wages and amount of contribution shown above and those shown in the last month's return suitable explanation should be given in the 'Remarks'
Column.
(2) If any arrears of contributions or damages are included in the figures under columns 6 to 8, suitable details indicating the circumstances, amount, No. of subscribers and the period involved should be
furnished in the 'Remarks' column or on the reverse.
(3) Remittance shall invariably be made by deposits in the State Bank of India or its subsidiaries.
                                               FORM 10
             [Paragraph 36(2)(a) & (b) of the Employees' Provident Funds Scheme, 1952
      Return of Members leaving service during the month of ……………………………………
     Name and address of the Factory/Estt. ………………………… Code No. ………………………..

                                         Father's name (or
                                                               Date of * Reasons for
Sl. Account     Name of member (in       husband's name in
                                                               leaving    leaving        Remarks
No.   No.         Block letters)          case of married
                                                               service    service
                                             woman)
 1       2                3                      4                5           6              7


Date :                                           Signature of the employer or other authorised officer
                                                                         Stamp of the Factory / Estt.
    *Please state whether the member is (a) retiring according to Para 69(1)(a) or (b) of the scheme,
(b) leaving India for permanent settlement abroad, '(c) retrenchment, (cc) part or a total
disablement due to employment injury, (d) ordinarily dismissed for serious and wilful misconduct, (e)
discharged, (f) resigning from or leaving service, (g) taking up employment elsewhere. (The name
and address of the Employers should be stated), (h) Death, (i) attained the age of 58 years.
    A request for deduction for the account of a member dismissed for serious and wilful misconduct
should be reported by the following certificate:
      "Certified that the member mentioned at serial No. ………………………… Shri
………………………………………...…….……..                                                                          For
…………………………………..……………..should be forfeited from that account in the fund. A copy
of the order of dismissal is enclosed."
      "Certified that the member mentioned at serial No. ……………………….. Shri
…………………………………………………………………. Was paid/not paid retrenchment
compensation of Rs. ………………………………………….. Under the Industrial Disputes Act,
1947."

(Also filled in Form No. 5)                                                Signature of the Employer
* Please Strike out which ever is not applicable
                                                                   FORM 6A
                                         The Employees' Provident Fund Scheme, 1952 (Paragraph 38(3))
Annual Statement of Contribution for the currency period from 1st           Statutory rate of contribution …………………… No. of members
……………….…..20 to ……………..……20                                                 Voluntarily contributing at a higher rate ……………………
Name and address of the factory/establishment …………………………………………………………………………………………………………
Code No. of the factory/establishment …………………………………………………………………………………………………………………….

                                        Wages, retaining                         Employer's Contribution
                                                              Amount of worker's                                      Rate of higher
                  Name of the      allowance (if any) and D.                          EPF
Sl.                                                             contributions                             Refund        voluntary
    A/c No.       members (in      A. including cash value of                     difference  Pension                                    Remarks
No.                                                           deducted from the                          advances     contribution (if
                  block capital)     food concession paid                        between 12 fund 10%
                                                                   wages                                                   any)
                                       during the currency                        % & 10 %
(1)     (2)            (3)                      (4)                  (5)               (6)       (7)        (8)             (9)           (10)


Reconciliation of Remittances      Total Rs.                  Rs.                             Rs.                   Rs.

                                                                  Amount Remitted
                                                                Pension Fund        EDLI
Sl.              Amount remitted EPF contribution including                                   Admin. Charges Rs. At Aggregate contribution Cols.
    Month                                                      Contribution A/c. Contribution
No.                   refund of advances A/c. No. 1                                             1.10% of wages             5+6+7 (Rs.)
                                                                   No. 10        A/c. No. 21
 1       2                           3                                4               5           6          7                  8
                                                                                             EDLI
   Mar.                                                                          Admin
                                                                                             Admin
 1 Paid       in Rs.               Rs.                        Rs.                Charges A/c
                                                                                             Charges
   April                                                                         No. 2 Rs.
                                                                                             0.01 % Rs.
 2    April     Rs.                Rs.                        Rs.
 3    May       Rs.                Rs.                        Rs.
 4    June      Rs.                Rs.                        Rs.
 5    July      Rs.                Rs.                        Rs.
 6    Aug.      Rs.                Rs.                        Rs.
 7    Sept.     Rs.                Rs.                        Rs.
 8    Oct.      Rs.                Rs.                        Rs.
 9    Nov.      Rs.                Rs.                        Rs.
10    Dec.      Rs.                Rs.                        Rs.
11    Jan.      Rs.                Rs.                        Rs.
   Feb.
12 Paid in Rs.                  Rs.                        Rs.
   March
   Arrear, if
13            Rs.               Rs.                        Rs.
   any
   Total      Rs.               Rs.                        Rs.

Remarks :
(1) Total number of contribution cards enclosed (Form 3A Revised)
(2) Certified that the Forms 3A duly completed, of all the members listed in this statement are enclosed, except those already sent during the
course of the currency period for the final settlement of the concerned members's accounts vide 'Remarks' furnished against the name of the
respective members above.

                                                                                                                             Signature of employer
                                                                                                                                   with office seal.
                                                                FORM 6 (Revised)
                                              THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
                                                                (See Paragraph 43)
Return of the Contribution Cards sent to the Commissioner on the expiry of the Period of Currency from ………………...… to ……………..……
Name and Address of the Factory Establishment ………………………………………………………………………………………………………
Code No. of the Factory/Establishment …………………………………………………………………………………………………………………

                                                 Employers' Total           Members' Total
                                                  Contribution               Contribution
Sl.                 Name of the member (in
      Account No.                                                                                  Amount refunded           Remarks
No.                     block letters)       E. P. F. E. P. F. TOTAL E. P. F. E. P. F. TOTAL
                                                      at 1 1/6 %              at 1 1/6 %
                                                Rs.      Rs.     Rs.    Rs.      Rs.     Rs.
 1        2                   3                            4                       5                       6                     7


Total number of cards sent ……………………..                          Signature of the Employer or other authorised officer of Factory Establishment
Date : ……………………………. 20                                                                                     Stamp of the Factory/Establishment
                                               FORM 3A
                      THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
                                        (Paragraphs 35 and 42)
                                                  AND
                             THE EMPLOYEES' PENSIONS SCHEME, 1995
                                               (Para 19)
                                Contribution card for the currency period
            from 1st April, 20 ………………………..to 31st March ……………………….., 20
                                (For Unexempted Establishments only)

Contribution Card for the currency period from ……………………… to ……………………………..
1 Account No. …………………………………………………………………………………………..
2. Name …………………………………………………..Surname …………………………………..
                                            (In Block Capitals)
3. Father's/Husband's Name …………………………………………………………………………
4. Name and address of factory/establishment ……………………………….………………………
5. Statutory rate of contribution ………………..……………………………….………………………
6. Voluntary, higher rate of Employee's contribution, if any …………………..………………………

                                        CONTRIBUTIONS
            WORKERS'S             EMPLOYER'S SHARE
                                                                 No. of
                                                              days/period
                        EPF difference Pension Fund            of service
Months Amount of                                    Refund of
                 E.P.F. between [ 12 % Contribution               non-                      Remarks
        wages                                       advances
                         & 10], if any    [10%]               contributing
                                                               service (if
                                                                  any)
    1         2         3          4(a)             4(b)           5            6               7
 March
Paid in
April
May
June                                                                                        A) Date of
July                                                                                      leaving service
August                                                                                         if any.
Sep.                                                                                       B) Reason for
Oct.                                                                                     leaving service,
Nov.                                                                                            if any
Dec.
Jan.
Feb.
March

Certified that the total amount of contributions (both shares) indicated in this card i.e., Rs. …………….
Has already been remitted in full in EPF A/c. No. 1 (P. F. A/c.) and A/c. No. 10 ……………….. Vide
Note below.

Certified that the difference between the total of the contribution shown under columns 3 and 4(a) and
4(b) 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 of contributions to the nearest rupee under the rules.

Dated ………………….20                                                              Signature of the Employer
                                                                                       (Office Seal)
NOTE :- (1) In respect of the Form (3A) send 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, should be furnished under col. 7(a) and (b).
(2) In respect of those who are not members of the Pension Fund, the employer's share of
contribution to the EPF will be [10% to 12%] as the case may be and is to be shown under col. 4(a).
                                      FORM 3
                        (For unexempted Establishments only)
                 THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
                               (Paragraphs 35 and 42)
                        (For Unexempted Establishments only)

Contribution Card for the currency period from ……………………… to ……………………………..
1 Account No. …………………………………………………………………………………………..
2. Name …………………………………………………..Surname …………………………………..
                                         (In Block Capitals)
3. Father's/Husband's Name …………………………………………………………………………
4. Name and address of factory/establishment ……………………………….………………………
5. Statutory rate of contribution ………………..……………………………….………………………
6. Voluntary, higher rate of Employee's contribution, if any …………………..………………………
7. Age ………. …………………………………………………………………………………………..
8. Occupational/Job ……………………………………………………………………………………..
9. Income per month ,,…………………………………………………………………………………..
10. Permanent/Temporary/Contractual .………………………………………………………………..

                                 CONTRIBUTIONS
         MEMBERS'S SHARE        EMPLOYER'S SHARE
               F.P.F.             F.P.F.                Break in member-
                                              Refund of
 Months E.P.F. @ 1- TOTAL E.P.F. @ 1- TOTAL              ship/reckonable Remarks
                                              advances
               1/6 %              1/6 %                      service
          Rs.    Rs.  Rs. Rs. P. Rs. P Rs. P.   Rs. P.   From        To
April
May
June
July
August
Sep.
Oct.
Nov.
Dec.
Jan.
Feb.
March

TOTAL


Dated ………………….20                                            Signature of the Employer
                                                                     (Office Seal)
                                              FORM 5
                     THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
                                      [Paragraph 36(2)(a)] and
                           Employees' Pension Scheme, 1995 [Para 20(4)]
                                         (Paragraph 15(2))
Return of employees qualifying for membership of the Employees' Provident Fund, Employees Pension
    Fund and the Employees Deposit-Linked Insurance Fund for the first time during the month of
                               ……………………………………………..
                    [To be sent to the Commissioner with Form 2 (EPF & EPS)]
 Name and Address of the Factory/Establishment ………………………………………………………….
 Code No. of Factory/Establishment …………………………………………………………………………

                                                                      Total period of
                                                                      previous service
                                  Father's name of                    as on the date of
             Name     of     the                             Date of
Sl.                               Husband's name Date of              joining the Fund
    A/c. No. Employee         (in                        Sex joining                     Remarks
No.                               (in    case   of Birth              (Enclose
             block Capitals)                                 the fund
                                  married woman)                      Scheme
                                                                      Certificate     if
                                                                      applicable)



Date ………           Signature of the employer or any other authorised officer of the Factory / Establishment
                                                                      Stamp of the Factory/Establishment
1. This form should be accompanied by declaration and nomination in form 2 (EPF)
2. All particulars to be filled in CAPITAL LETTERS.
                                              FORM 5-A
                             (For Exempted/Unexempted Establishments)
                      THE EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952
                                        (See Paragraph 36-A)
                       THE EMPLOYEES' PENSION SCHEME, 1995 (Para 21)
                  THE EMPLOYEES' DEPOSIT-LINKED INSURANCE SCHEME, 1976
                                          (See Paragraph 1)
Return of ownership to be sent to the Regional Commissioner.
1. Name of the establishment ………………………………………………………………………………
2. Code Number of the establishment under U. P. the Employees' Provident Funds and Miscellaneous
Provision Act, 1952 …………………………………………………………………………
3. Postal address of the establishment and its branches/departments, if any …………………………
4. Industry of business in which engaged ………………………………………………………………….
5. Date of first commencement of production/business (Trial/Regular) ……..………………………….
6. Date of Closure by the previous management ………………..……………………………………….
7. Whether run by the owners of lesses (if by lessees, period of the lease should be indicated)
………………………………………………………………………………………………………………….
8. Particulars of Owners …………………………………………………………………………………….

                                                                                             Date      from
Name                         Age Status*         Father's name    Residential address        which        in
                                                                                             position
              (a)             (b)       (c)              (d)                  (e)                  (f)
(i)
(ii)
(iii)

* Whether proprietor, Partner, Mg. Partner, Mg. Director, Director, etc.

9.      If on lease, particulars of lessees :
                                                                                             Date      from
Name                         Age              Father's name       Residential address        which        in
                                                                                             position
              (a)             (b)                  (c)                        (d)                  (e)
(i)
(ii)
(iii)

10.      If registered under the Factories Act, particulars of the Manager/Occupier :
                                                                                             Date      from
Name                         Age              Father's name       Residential address        which        in
                                                                                             position
              (a)             (b)                  (c)                        (d)                  (e)
(i)
(ii)
(iii)

A. Occupier.
B. Manager.

11. Particular of the person mentioned above, who are in charge of, and responsible for the conduct
of the business of the establishment :

Name                         Age              Father's name                  Residential address
         (a)            (b)               (c)                                  (d)
(i)
(ii)
(iii)

Dated ………… 20                                                              Signature of the Employer
                                                                          (Seal of the establishment)
                                                                            Seal of the establishment

NOTE : Any change in the information given above should be intimated in writing to the Regional
Commissioner within fifteen days of such change by registered post and in the prescribed manner
under copy to the Provident Fund Inspector.

				
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