Employees Provident Fund Scheme

Form 3 A (Revised)
(For unexempted Establishments only)
The Employees Provident Funds Scheme, 1!"
(See p#r#$r#phs 3! % &")
Contribution Card for the currency period From 1
st
, 19 to 30
th
/31
st
, 19
1 !ccount "o
# "ame /$urname
(in bloc% capitals)
3 Father&s / 'usband&s "ame
( "ame ) !ddress of the Factory/Establishment
* $tatutory rate of the Contribution
+ ,oluntary hi-her rate of employee&s contribution, if any
'ontri(utions
!mount of
.a-es
.or%er&s $hare Employer&s $hare /rea% in
membershi
p/rec%onab
le ser0ice
1em
ar%s
E2F 12F 3otal E2F 12F 3otal 1efund
of
ad0anc
e
(1) (#) (3) (() (*) (+)
Months
!pril
4ay
5une
5uly
!u-ust
$eptember
6ctober
"o0ember
7ecember
5anuary
February
4arch
3otal
(a) 7ate of lea0in- ser0ice
(b) 1eason for lea0in- ser0ice
(c) Certified that the total amount of contributions (both shares) indicated in this card ie
1s 8Column (3)(c)9 8Column (()(c)9 has already been remitted in full in
E2F !/c "o 1 (2F!/c) and !/c "o 10 (E2F !/c) (0ide note belo:)
Certified that the difference bet:een the total of the contribution sho:n under Cols 3 ) ( of the
abo0e table and that arri0ed at one the total :a-es sho:n in Column # at the prescribed rate is
solely due to roundin- off of contributions to the nearest rupee under the rules
7ated 19 $i-nature of the Employer
(Office Seal)
Note : In respect of the Form 3-A sent to the Regional Office during the course of the Currency period for the purpose of
final settlement of the accounts of the members who had left service details of date and reasons for leaving service, and
also a certificate as shown in the Remar!s" columns should be added#