FORM 12-A (Revised) EMPLOYEES' PROVIDENT FUND AND MISC. PROVIDENT ACT, 1952 Only for Un-Exempted Establishment Establishment Status Name and Address of the Estt. M/S, __________________ Group Code ___________________ ___________________ Currency period from 1st April, 200 to 31st March, 200 Statement of contributions for the Month of Code No. Statutory rate of contribution G J % Amount of Contribution 3 Amount of contribution remitted 4 Particulars 1 Wages on which Contributi ons are payable 2 Recovered from the workers Payable by the employe r Worker's share Employe r's share Amount of Adminis trative charge due 5 Amount of Administrati ve charges remitted 6 Date of Remittance (enclose triplicate copies of Challan) E.P.F. A/c No. 01 Pension Fund A/C No. 10 NIL NIL NIL NIL D.L.I. A/C No. 21 NIL NIL NIL NIL Total No. of Employees a. Contract Name and address __________________ b. Rest of the bank in which __________________ the amount is remitted_________________ 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 From 5) No. of New Subscribers left service (Vide Form 10) (Nett.) Total Number of Subscribers Signature of the Employer with official Seal
