EMPLOYEES� STATE INSURANCE CORPORATION - DOC by aON8rQ

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									                     EMPLOYEES’ STATE INSURANCE CORPORATION                                       ORIGINAL
                          Challan Form for Deposit in A/c No. 1                                    For Bank

Employer’s Code
Region code              Employer code            Industry            Date       Month               Year
                                                    Code



                                                             Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ( )]
Cash                                 Cheque/D.D.No.                                      Dated:
Cheque                               Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution               Month                                   Year
                                     Regular Contribution                    Interest             Damages
Nature of Payment [Tick (   )]
                                                                             Others

Total Wages : Rs.

No. of Employees:
                                                                                        Rs.                   Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________
                                    ______________________________________
         Bank                                       Signature
         Seal                          ______________________________________
                                  Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
                            Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs.                                                                       For use in Bank
(Rs…………………………………………………………………..only)                                Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to            Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1    Authorised signature & Seal of the Receiving
                                                                   Bank

*(For Bank Branch Code see on reverse)                 Important: Affix Correct Code No. Name Seal
                                                       and Period of contribution to avoid missing credit
                     EMPLOYEES’ STATE INSURANCE CORPORATION                                        DUPLICATE
                          Challan Form for Deposit in A/c No. 1                               For ESIC through Bank

Employer’s Code
Region code              Employer code             Industry           Date       Month                 Year
                                                     Code



                                                              Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ( )]
Cash                                 Cheque/D.D.No.                                      Dated:
Cheque                               Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution                Month                                  Year
                                      Regular Contribution                   Interest               Damages
Nature of Payment [Tick (   )]
                                                                             Others

    Total Wages : Rs.

No. of Employees:
                                                                                        Rs.                    Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date
____________________________________________________________________________________
                                    ______________________________________
         Bank                                       Signature
         Seal                          ______________________________________
                                 Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
                            Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs.                                                                       For use in Bank
(Rs…………………………………………………………………..only)                                Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to            Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1    Authorised signature & Seal of the Receiving
                                                                   Bank

*(For Bank Branch Code see on reverse)                  Important: Affix Correct Code No. Name Seal
                                                        and Period of contribution to avoid missing credit
                     EMPLOYEES’ STATE INSURANCE CORPORATION                                       TRIPLICATE
                          Challan Form for Deposit in A/c No. 1                                   For Depositor

Employer’s Code
Region code              Employer code             Industry           Date       Month                 Year
                                                     Code



                                                              Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ( )]
Cash                                 Cheque/D.D.No.                                      Dated:
Cheque                               Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution                Month                                  Year
                                      Regular Contribution                   Interest               Damages
Nature of Payment [Tick (   )]
                                                                             Others

    Total Wages : Rs.

No. of Employees:
                                                                                        Rs.                       Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date
____________________________________________________________________________________
                                    ______________________________________
         Bank                                       Signature
         Seal                          ______________________________________
                                 Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
                            Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs.                                                                       For use in Bank
(Rs…………………………………………………………………..only)                                Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to            Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1    Authorised signature & Seal of the Receiving
                                                                   Bank

*(For Bank Branch Code see on reverse)                  Important: Affix Correct Code No. Name Seal
                                                        and Period of contribution to avoid missing credit
                    EMPLOYEES’ STATE INSURANCE CORPORATION                                 QUADRUPLICATE
                         Challan Form for Deposit in A/c No. 1                          For Depositor to be attached
                                                                                        with Return of contributions
Employer’s Code
Region code              Employer code             Industry           Date       Month                 Year
                                                     Code



                                                              Bank & Branch Code*

Name of Factory
/ Estt. & Address

Mode of Payment [Tick ( )]
Cash                                 Cheque/D.D.No.                                      Dated:
Cheque                               Drawn on (Name of the Bank/Branch)
D.D.

Period of contribution                Month                                  Year
                                      Regular Contribution                   Interest              Damages
Nature of Payment [Tick (   )]
                                                                             Others

    Total Wages : Rs.

No. of Employees:
                                                                                        Rs.                     Ps.
Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………
Total amount (in words)
____________________________________________________________________________________
R.O. Demand Letter No. & Date
____________________________________________________________________________________
                                    ______________________________________
         Bank                                       Signature
         Seal                          ______________________________________
                                 Name & Designation – Seal of Authorised Signatory
____________________________________________________________________________________
                            Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________

Received Rs.                                                                       For use in Bank
(Rs…………………………………………………………………..only)                                Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to            Date: ……………………………….
Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1    Authorised signature & Seal of the Receiving
                                                                   Bank

*(For Bank Branch Code see on reverse)                  Important: Affix Correct Code No. Name Seal
                                                        and Period of contribution to avoid missing credit

								
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