NAME TICKET NO. DEPARTMENT OCCUPATION .

NAME OF FACTORY YEAR2009 . JAN. FEB. MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
PART I - ADULTS TOTAL WORKING DAYS DURING THE MONTH LEAVE WITH WAGE TO CREDIT
PART I - CHILDERN NO. OF DAYS WORK PERFORMED BALANCE OF LEAVE WITH WAGES
SERIAL NO. a) AUTHORISED LEAVE/MATERNITY LEAVE WITH WAGES FROM PRECEDING YEAR DAYS .
b) LOCKOUT & LEGAL STRIKE LEAVE WITH WAGES EARNED
c) LEAVE WITH WAGE ENJOYED DURING THE YEAR DAYS .
NAME OF WORKER d) INVOLANTARY UNEMPLOYMENT OR DAYS OF LAY-OFF TOTAL LEAVE DUE YEAR DAYS .
e) SICKNESS & ACCIDENT LEAVED WITH WAGES FROM TO DAYS .
FATHER'S NAME f) CASUAL LEAVE ENJOYED FROM TO DAYS .
g) PAID HOLIDAY REM. PAID AMT. DATE .
TICKET NO. DEPARTMENT h) ABSENT / OTHER REM. PAID AMT. DATE .
BALANCE OF LEAVE TO CREDIT
OCCUPATION :- NORMAL RATE OF WAGE
DATE OF ENTRY INTO SERVICE
YEAR2010 . JAN. FEB. MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
WHETHER LEAVE WITH WAGES TOTAL WORKING DAYS DURING THE MONTH LEAVE WITH WAGE TO CREDIT
REFUSED IN ACCORDANCE WITH NO. OF DAYS WORK PERFORMED BALANCE OF LEAVE WITH WAGES
SCHEME UNDER SECATION 79 (8) 20 a) AUTHORISED LEAVE/MATERNITY LEAVE WITH WAGES FROM PRECEDING YEAR DAYS .
b) LOCKOUT & LEGAL STRIKE LEAVE WITH WAGES EARNED
WHETHER LEAVE WITH WAGES c) LEAVE WITH WAGE ENJOYED DURING THE YEAR DAYS .
NOT DESIRED DURING THE NEXT d) INVOLANTARY UNEMPLOYMENT OR DAYS OF LAY-OFF TOTAL LEAVE DUE YEAR DAYS .
CALENDAR YEAR 20 e) SICKNESS & ACCIDENT LEAVED WITH WAGES FROM TO DAYS .
f) CASUAL LEAVE ENJOYED FROM TO DAYS .
CASH EQUIVALENT OR ADVANTAGE g) PAID HOLIDAY REM. PAID AMT. DATE .
ACCORDING THROUGH h) ABSENT / OTHER REM. PAID AMT. DATE .
CONCESSIONS SALE OF BALANCE OF LEAVE TO CREDIT
FOOD-GRAINS OR OTHER ARTICLES 20
RATE OF WAGES FOR LEAVE
WITH WAGE PERIOD 20 YEAR2011 . JAN. FEB. MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
TOTAL WORKING DAYS DURING THE MONTH LEAVE WITH WAGE TO CREDIT
NO. OF DAYS WORK PERFORMED BALANCE OF LEAVE WITH WAGES
a) AUTHORISED LEAVE/MATERNITY LEAVE WITH WAGES FROM PRECEDING YEAR DAYS .
DATE OF DISCHARGED :- b) LOCKOUT & LEGAL STRIKE LEAVE WITH WAGES EARNED
c) LEAVE WITH WAGE ENJOYED DURING THE YEAR DAYS .
DATE AND AMOUNT OF PAYMENT MODE IN LIEU OF LEAVE WITH WAGES DUE:- d) INVOLANTARY UNEMPLOYMENT OR DAYS OF LAY-OFF TOTAL LEAVE DUE YEAR DAYS .
e) SICKNESS & ACCIDENT LEAVED WITH WAGES FROM TO DAYS .
f) CASUAL LEAVE ENJOYED FROM TO DAYS .
20 Rs. g) PAID HOLIDAY REM. PAID AMT. DATE .
h) ABSENT / OTHER REM. PAID AMT. DATE .
20 Rs. BALANCE OF LEAVE TO CREDIT
20 Rs.
YEAR2012 . JAN. FEB. MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
TOTAL WORKING DAYS DURING THE MONTH LEAVE WITH WAGE TO CREDIT
NO. OF DAYS WORK PERFORMED BALANCE OF LEAVE WITH WAGES
a) AUTHORISED LEAVE/MATERNITY LEAVE WITH WAGES FROM PRECEDING YEAR DAYS .
b) LOCKOUT & LEGAL STRIKE LEAVE WITH WAGES EARNED
c) LEAVE WITH WAGE ENJOYED DURING THE YEAR DAYS .
d) INVOLANTARY UNEMPLOYMENT OR DAYS OF LAY-OFF TOTAL LEAVE DUE YEAR DAYS .
e) SICKNESS & ACCIDENT LEAVED WITH WAGES FROM TO DAYS .
f) CASUAL LEAVE ENJOYED FROM TO DAYS .
g) PAID HOLIDAY REM. PAID AMT. DATE .
h) ABSENT / OTHER REM. PAID AMT. DATE .
BALANCE OF LEAVE TO CREDIT
DATE PAYMENT


DISCHARGED WORKER
LEAVE BOOK
FORM NO.20(Rule 105) REGISTER OF LEAVE WITH WAGES




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