The Employee's Provident Fund Scheme 1952 (Paras 35 & 42) and The Employees' Pension Scheme, 1995

(Para 19) (Form 3A (Revised) f.!fq

CONTRIBUTION CARD FOR CURRENCY PERIOD FORM 1ST APRIL 200 TO 31 ST MARCH 200
1 _;j c'! 200 0 31 200 tlq, 3mGR m m
Account No.............................. 2. Name/Surname (in block capitals)......................................
'ffiJ!IT -111l/ ( 3iffil l'i)
4 Name & Address of the Factory 5. Statutory rate of Contribution................................................
Establishment............................... 3mGR

/ -1'J1l <f 'C@l

CONTRIBUTION 3mc:A
Month ll'm Worker's Share Employer's Share f.rm<lffi ft'ffiT Refund of Adv.
ft'ffiT 3tfiril
· ·
Amount of wages EPF EPFdifference between 12% & PENSION FUND
<ti') 'If;. 'If. f.!. 8.33% (if any) AA 12%3IR'ifi ContributionB.33%
8.33% ,t;;ft,q 31'-ffi' AA3ffiGPr
mm)

1 2 3 4a 4b 5
March Paid in April
z;t

Mayl{{
June vj;I
July
August WTffl
Sept.
Oct.
Nov. '

Dec.
Jan.
Feb.
Feb. Paid in
March
Total
Certified that the total amount of contributions (both shares\ indicated in this Card i.e. Rs..............has already been remitted in full in EPF Ale. No. 1 a
wnfi)rn f$m uTim t fl$ m-i'i (c:r-TT 3tlr) 3ierro ......:......................
trrn t\ AA mil 1 3lR -q AA mil
10...............................l.'i \il1'!T l']1:[ t )
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 w
rounding off of contributions to the nearest rupee under the rules.
w:nfv@ f$m uTim t fl$ cfi 'ifiIB1f 3 3ITT 4 'If; 4« cfi 1'fl) 3ffi<:'A 3ITT 'ifiIB1f 2 i'f '1Jl
'-<) ll ffl cfi <tiR'VT 3lTm t I
Date ...........................2000 f.rm
<ti') mm,- withofficeseal
Nae (1) In respect of the form 3A sent to the Regional Office during the course of the currency period for the purpose of final settlement of the
leaving service should be furnished under Col. 7 (a) &(b).
illti cfi <Ira 'ifi 'ifi <li'r w,) cfra 3 'ifi 7 (if,) 3lR {«) 'ifi 3ltlR <ti') 3lR c
(2) In respect of those who are not members of the Pension Fund the employers share of contribution to the EPF will be 10% or 12% as the
under column 4 (a). ur) AA cfi ;,-gf t AA cfi 3fflGR <ti') 10% 3'1 12% ur) '!fr ID <lil<,1l 4 (if,) cfi I
 19) (Form 3A (Revised) f.!fq . 1952 (W 35 42) 31R m . 1995 (w 19)
(For unexempted establishment Oni\')
(lN-513 A (fimfm,)

( 3ftlc! 3{1 )
3. Father's/Husband's Name.......................................
/ttf<t <liT ,rrq
6. Voluntary higher rate of employee's
Contribution if any.........................................................

m 3mGA . mm
Refund of Adv. No. of days/period of non- contributing Remarks
3tfiril service (if any)
· ·
3ffiGP[ ;i- m mrr
m?m ( mm)

5 6 7
(a) Date of leaving service,
if any
(if,) <ti')
( m)

(b)Reason for leaving

service, if any (if,)
<tiR'VT ( mm)

remitted in full in EPF Ale. No. 1 and Pension Fund Ale No. 10 (Vide note below.)

ble and that arrived at on the total wages shown in column 2 at the prescribed rate is solel · due to

'1Jl l']1:[ 3mGA cfi ;ft,q 3RR Pt<l'11jtl,

f.rm<lffi cfi llR Signature of employer

e purpose of final settlement of the accounts of the member who has left service.details of date & reasons for

3ltlR <ti') 3lR cfiR1II uJR" I

he EPF will be 10% or 12% as the case may be & is to be shown
) cfi I