COMBINED CHALLAN OF A/C NO.

1,2,10,21,& 22 ( STATE BANK OF INDIA )

Orignal Duplicate

EMPLOYEE'S PROVIDENT FUND ORGANISATION

Triplicate

( USE SEPARATE CHALLAN FOR EACH MONTH )

Quadruplicate

ESTABLISHMENT CODE NO.:

GJ/54975 June 2011

PF Group :EMPLOYEE SHARE EMPLOYER SHARE

PAID BY CASH/CHEQUE/D.D
D 12.00 % D M M Y Y

DUES FOR THE MONTH OF :-

DATE OF PAYMENT

12.00 %

TOTAL No. of SUBSCRIBER TOTAL WAGES DUES

A/c No. 1

{
526.00 1720.00

6 14330.00

A/c No. 10

{
1194.00

6 14330.00

A/c No. 21

6 14330.00

Sr. No
1

Particulars

A/c No. 1

A/c No. 2

A/c No. 10

A/c No. 21

A/c No. 22

Total

EMPLOYER'S SHARE OF CONT EMPLOYEE'S SHARE OF CONT ADMN. CHARGES INSP. CHARGES PENAL CHARGES MISC. PAYMENTS

72.00

1792.00
1720.00

158.00

2.00

160.00

2246.00 TOTAL

158.00

1194.00

72.00

2.00

3672.00

Amount In Words

Three Thousand Six Hundred Seventy Two Only

( For Bank Use Only )

NAME & ADDRESS OF FACTORY/ESTABLISHMENT

MEDIZON (UNIT OF MEDIMARK BIOTECH)

Amount Received Rs. For Chq. /D.D Only. Date Of Realisation Date of Presantion

AHMEDABAD

NAME OF DEPOSITOR

For , MEDIZON (UNIT OF MEDIMARK BIOTECH)

Branch Name Branch Code

SIGNATURE OF DEPOSITOR ( TO BE FILLED IN BY EMPLOYER ) Name Of Bank Chq./D.D No.:Date