FORM 12-A (REVISED)

THE EMPLOYEES' PROVIDENT FUNDS & MISC. PROVISION ACT, 1952

EMPLOYEES' PENSION SCHEME [PRARGRAPH 20(4)]
Only for Un-Exempted Establishments
Name and address of the Establishment (To be filled in by EPFO)

Currency period from 1st April to 31st March Establishment Status

Statement of Contributions for the month of

Code No. Statutory Rate of Contribution % Group Code

Particulars Wages on which Amount of Contributions Amount Amount Date of

Amount of Contribution
Contributions Remitted of of Remittace
are Payable 3 4 Admin Admin (Enclose Triplicate
Recovered Payable by the Worker's Employer's Charges Charges Copies of Challan)
from the Employer Share Share Due Due
Worker
1 2 5 6
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

Total No. of Employees Name and address

(a) Contract of the Bank in which
(b) Rest amount is remitted:
(c) Total

Pension
Details of Subscribers E.P.F. E.D.L.I.
Scheme
Number as per last month's
return
+) Number of Subscribers vide Form
No. 5
-) Number of Subscribers vide
Form No. 10
Net total Signature of Employer with Office Seal