Most Immediate

Ps
Employees' Provident Fund Organisation
(Ministry of Labour & Employment, Govt. Of India)
Head.Office, Bhavishya Nidhi Bhawan,
14-Bhikaiji Cama Place, New Delhi-110066
No. Bkg.1(3)2009/Combined Challan/ Date:31.03.2010
To
All ACCs(Political States),
Ail R. P.F. RO/SRO
1

Subje:t: The Sub-Group on Labour constituted by High Level Task Force under the
Chairmanship of Principal Secretary to Hon'ble Prime Minister to address the
issues of Micro, Small and Medium Enterprises — issue of common challan form
for PF and ESI dues.

Sir/Madam,

I am directed to forward herewith copy of the common challan form for depositing PF and ESI
dues by the employers with the request to get sufficient number of new challans printed and distribute it
in your Offic/ among employers so that the employers could deposit contribution in the new format of
challan from April, 2010.
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This issues with the approval of CPFC.

Yours fi3ithfully,

End: As above
(R. K. Singh)
Regional P.F. Commissioner( F & A)

Copy to:
RPFC(NDC) with request to place this circular on website also.
 CHALLAN FORM FOR PAYMENT OF EMPLOYEES’ STATE INSURANCE/EMPLOYEES PROVIDENT CONTRIBUTION**

1 Name & Address of factory/establishment

EPFO ESIC
2 Establishments Code Number

3 Number of Subscribers/Employees

4 Total Wages EPF ESIC

EPS

5 Month of contribution EPFO ESIC

M M Y Y M M Y Y

A:EPF Account Number B: ESI Fund
I II X XXI XXII TOTAL Account No.1
Employers’ contribution
Employees’ contribution
Adm. Charges
Inspection Charges
Interest
Damages
Others/demand letter no. & date
Total

Mode of Payment Cheque/DD No Dated ‐ ‐ Cash

D D M M Y Y Y Y

Bank Name

Signature
Name, designation & Seal of Authorised official
Contact No.

**strike out whichever is not applicable

Acknowledgment
Received Rs For use in Bank
Rupees Branch Name
Branch Code No
Bank Scroll No
Cash/Cheque/DD No dated Date
Drawn on
Date of Presentation ‐ ‐
Date of Realisation ‐ ‐
Date of Credit ‐ ‐ Authorised Signature & Seal of Receiving Bank
D D M M Y Y Y Y