(For Un-Exempted Establishments) Address of the Establishment:
FORM 12 - (REVISED)
EMPLOYEES' PROVIDENT FUND AND MISC. PROVISIONS ACT,1952 EMPLOYEES' PENSION SCHEME [ PARAGRAPH 20(4)] Currency Period from 1st April to 31st March, Statement of Contributions for the Month of Statutory rate of Contribution 12%
(To be filled by the EPFO) Establishment Status Group Code
code number:
Wages on which contributions are payable (2) Amount of Amount of Administrative Administrative charges Date of remiitance charges due remitted (enclose triplicate (5) (6) copies of challan)
Particulars (1)
Amount of Contribution Amount of Contribution (3) remitted (4) Recovered from Payable by the Worker's Employer's the workers employer share share
E.P.F.A/c No. 01 Pension Fund A/c No. 10 D.L.I. A/c No. 21 TOTAL AMT.PAID Total No. of Employees ( a ) Contract ( b ) Rest ( c ) Total Details of Subscribers No.of subscribers as per last month No.of New Subscribers (vide Form 5) No.of subscribers left service (vide Form 10) (Nett.) Total No.Of subsribers
0-Jan-1900 0-Jan-1900 0
Name and Address of the Bank in which the amount is remitted State Bank of India, T.Nagar Branch Chennai - 600 017
0 0 E.P.F. Pension Fund E.D.L.I. 0 0 0 0 0 0
For
AUTHORISED SIGNATORY 0 0 0 Dt.