Form 3A (Revised)

Employees provident fund scheme 1952 (Para 35&42) & the employees pension scheme 1995 (Para 19) CONTRIBUTION CARD FOR CURRENCY PERIOD FROM 1ST _______________ TO _____________
1. Account No.: 2. Employee Name: 3. Father/Husband Name: 4. Name and Address of Factory/Establishment 5. Statutory rate of contribution Refund of Advance No of days/ period of noncontribution Worker share Amount of Wages Employer share Pension fund contribution EPF contributionPension fund contribution 6. Voluntary higher rate of employees contribution if any 7. Employees contribution of higher wages to EPF Yes/No 8. Employees contribution to pension fund on higher wages Yes/No 9. Date on which 6500 wages started

March paid in April April paid in May May paid in June June paid in July July paid in Aug Aug paid in Sep Sep paid in Oct Oct paid in Nov Nov paid in Dec Dec paid in Jan Jan paid in Feb Feb paid in March Supplementary if any Total

a) Date of Leaving

Certified that the total amount of contribution (both shares) indicated in this card i.e. Rs. has already been remitted it full in E.P.F. A/c No. 1) and PensionFund A/c No.10 - Rs Certified that the difference between the total of the contribution shown under Cols. 3 & 4a & 4b of the above table and that arrived at on the total wages shown in column 2 at the prescribed rate is solely due to rounding off the contributions to the nearest rupee under the rules

Date :

Signature of the Employer(with office seal)

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Remarks b) Reasons for Leaving

Month

EPF