Employees Provident Fund Scheme

Form 5-A
(For exempted /unexempted Establishments)
The Employees Provident Funds Scheme, 1952
[See Paragraph 36-A]
The Employees Pension Scheme, 1971
[See Paragraph 6]
AND
The Employees eposit ! lin"ed #nsur$nce Scheme, 197%
[See Paragraph ]
Return of Ownership to be sent to the Regional Commissioner (In Duplicate)
1. Name of the establishment
2. Code Number of the establishment under the Employees Provident Funds and
Misellaneous Provisions At! 1"#2
$. Postal address of the establishment and its branhes%departments! if any

&. 'ndustry or business in (hih en)a)ed
#. Date of first ommenement of prodution%business *+rial%,e)ular-

.. Date of losure by the previous mana)ement
/. 0hether run by the o(ners or lessees *if by lessees! period of the lease should be indiated-

1. Partiulars of o(ners
Name A)e 2tatus3 Fathers
Name
,esidential
Address
Date from
(hih in
position
A 4 C D E F
i.
ii.
iii.
! "hether Proprietor# Partner# $g% Partner# $g% &ire'tor# &ire'tor
". 'f on lease! Partiulars of lesses5
Name A)e Fathers
Name
,esidential
Address
Date from (hih in position
A 4 C D E
i.
ii.
iii.
16. 'f re)istered under the Fatory At. Partiulars of the Man)er%7upier.
Name A)e Fathers
Name
,esidential
Address
Date from (hih in position
A 4 C D E
A. 7upier
4. Mana)er
11. Partiulars of the persons mentioned above! (ho are in har)e of and responsible for the
ondut of the business of the establishment.
Name A)e Fathers Name ,esidential Address
A 4 C D
i.
ii.
iii
2i)nature of the Employer
Desi)nation
2eal of the establishment
Dated 266