(USE SEPARATE CHALLAN FOR EACH MONTH)

ORIGINAL

EMPLOYEES' PROVIDENT FUND ORGANISATION

ESTABLISHMENT CODE NO.DL DUES FOR THE MONTH OF: 33905 M Employees Share Employer Share Total No. of Subscribers Total Wages Due SL. NO PART - 01 1 EMPLOYERS' SHARE OF CONT. 2 EMPLOYEES' SHARE OF CONT. 3 ADMN CHARGES 4 INSP. CHARGES 5 PENAL DAMAGES PARTICULARS A/c. 1 A/C No.1 1 A/C No.2 A/c. 10 1 A/c. 21 A/C No.22 1 TOTAL M ACCOUNT GROUP NO Y Y Y Y DATE OF PAYMENT D D PAID BY CHEQUE M M Y Y Y * Y /CASH

A/C No.10 A/C No.21 AMOUNT (In Rupees)

6 MISC. PAYMENT 7 PAST ACCUMULATIONS TOTAL

(Amount in words

EIGHT HUNDRED NINTY NINE ONLY (For Bank's use only) Amount Received Rs. For Cheques only Date of Presentation Date of Realisation Branch Name Branch Code No. (TO BE FILLED BY EMPLOYER'S) CHEQUE NO: DATE : .

NAME OF ESTABLISHMENT : ADDRESS

NAME OF THE DEPOSITOR SIGNATURE OF THE DEPOSITOR NAME OF THE BANK

SERVICE ..