FORM - 12A

THE EMPLOYEES’ PROVIDENT FUND AND MISC. PROVIDENT ACT, 1952 (Revised)

EMPLOYEES’ PENSION SCHEME [ PARAGRAPH 20(4)]

(To be filled in by EPFO)
Establishment Status Group Code
Name and Address of the Establishment
Code No. H R / 0 0 0 0 0

Statutory Rate of Contribution 1 2 %

Currency period from 0 1 0 4 2 0 1 0 TO 3 1 0 3 2 0 1 1 Statement of contributions for the Month of 0 9 2 0 1 0

Wages on Amount of Contribution Amount Amount of

Amount of Contribution
which Remitted of Admin Admin Date of Remittance
Particulars
Contribution is Received Payable by
Worker's Employer's Charges Charges (enclose triplicate copies of Challan)
payable from the the Due Remitted
Share Share
Wroker Employer
1 2 3 4 5 6 D D M M Y Y Y Y

EPF A/c No.: - 1 - - - - - - - 2 0 1 0

Pension Fund A/c No.: - 10 - - - NIL 0 0 0 0 2 0 1 0

NIL NIL
D. L. I. A/c No.: - 21 - - - - - 0 0 0 0 2 0 1 0

Total No. of Employees

Name & Address of State Bank of India
a. Contract - the Bank in which
the Amount is
b. Rest - Remitted Rs. -
c. Total -

Details of Subscribers E.P.F. Pension Fund E.D.L.I.

No. of Subscribers as per last month - - -
No. of New Subscribers (Vide From 5) - - -
No. of New Subscribers left service (Vide Form 10) - - -
Signature of the Employer
(Nett.) Total Number of Subscribers - - - with official Seal