FORM - 3A

(Unexempted Establishment Only) THE EMPLOYEE'S PROVIDENT FUND SCHEME, 1952 (Paras 35 and 42) and THE EMPLOYEES PENSION SCHEME, 1995 Para 20

Contribution Card for the currency period from April

1. Account No. 2. Name/Surname: Chahal 3. Father/Husband's Name: 4. Name & Address of the Establishment :

2009 to March 31 2010

5. Statutoty Rate of Contribution : 6. Voluntary higher rate of Employees contribution, if any 12%

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Month

Amount of Wages Rs.

CONTRIBUTIONS Worker's Share Employer Share EPF EPF a EPS b TOTAL c

Refund of Non cont. Advances services from --------To---------

Remarks

1
April May June July August September October November December January February March April May June July August September October November December January February March April May June July August September October November December January February March 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010 2009 2009 2009 2009 2009 2009 2009 2009 2009 2010 2010 2010

7
a) Date of Leaving service

b) Reason for leaving service

Resignation
c) Certified that the total amount of contribution indicated in this card

i.e. Rs.

Col 3+Col4 ( c ) has already been remitted in full in EPF A/c No 1 ( Provident Fund contribution A/c) and in A/c no. 10 ( Pension Fund Contribution account vide note below )

Certified That the difference between the total of the contribution 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 of the contributions to the nearest rupee under the rule.
*Contribution for the month of March paid in April

Date :
Note: 1 ) 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 certificate as shown in the Remarks Column should be added. Note: 2 ) If there is no period of NCS, the word "NIL" to be mentioned against the total column. Note: 3 ) Wherever no wages are shown against any month the period should be shown as NCS Under Col. 6.

Signature of Employer (Office Seal)

FORM - 3A
(Unexempted Establishment Only) THE EMPLOYEE'S PROVIDENT FUND SCHEME, 1952 (Paras 35 and 42) and THE EMPLOYEES PENSION SCHEME, 1995 Para 20

Contribution Card for the currency period from April

1. Account No. 2. Name/Surname: Chahal 3. Father/Husband's Name: 4. Name & Address of the Establishment :

2009 to March 31 2010

5. Statutoty Rate of Contribution : 6. Voluntary higher rate of Employees contribution, if any 12%

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Month

CONTRIBUTIONS Amount of Employer Share Wages Worker's Share Rs. EPS TOTAL EPF APPLICABLE EPF SALARY a b c

Refund of Non cont. Advances services from --------To---------

Remarks

1
April 2009 May 2009 June 2009 July 2009 August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 April May 2009 2009

7
a) Date of Leaving service

b) Reason for leaving service

Resignation
c) Certified that the total amount of contribution indicated in this card

i.e. Rs.

Col 3+Col4 ( c ) has already been remitted in full in EPF A/c No 1 ( Provident Fund contribution A/c) and in A/c no. 10 ( Pension Fund Contribution account vide note below )

Fund Contribution account vide note below )

June 2009 July 2009 August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 April 2009 May 2009 June 2009 July 2009 August 2009 September 2009 October 2009 November 2009 December 2009 January 2010 February 2010 March 2010 0 0 0 0 0 0