FORM A

STATEMENT OF EMPLOYEES' AND EMPLOYERS' CONTRIBUTION FOR THE SIX MONTHS ENDING ON THE 30TH JUNE AND THE 31ST DECEMBER, RESPECTIVELY

[See Rule 3(4)]
ANNEXURE

1. Name of the establishment
2. Name of the employer
3. Class of establishments (i.e. whether a factory of motor omni bus service, a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment).
4. Address of the establishment
5. Total number of employees whose names stands on the establishment register on the 30 th June/the 31 st December.
6.
(a) Employees' contribution at the rate of Rs. ______________
(b) Employers' contribution at the rate of Rs. ______________ Per employee,
7. Total of sub-entries (a) and (b) of entry 6.
8. Weather the contribution has already been paid to the Welfare Commissioner, if so, whether by cheque, money order or cash and details thereof.

Signature of the employer.
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Last Updated : 23 Mar,2014