FORM - 3A

(Unexempted Establishment Only) THE EMPLOYEE'S PROVIDENT FUND SCHEME, 1952 (Paras 35 and 42) and THE EMPLOYEES PENSION SCHEME, 1995 Para 20

Contribution Card for the currency period from April

1. Account No. 2. Name/Surname 3. Father/Husband's Name 4. Name & Address of the Establishment :

to March 31 5. Statutoty Rate of Contribution : 6. Voluntary higher rate of Employees contribution, if any 7. Whether opted to contribute on full salary for pension? Yes/No

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Month

Amount of Wages Rs.

CONTRIBUTIONS Worker's Share Employer Share EPF EPF a EPS b TOTAL c

Refund of Non cont. Advances services from --------To---------

Remarks

1
April May June July August September October November December January February March 200 200 200 200 200 200 200 200 200 200 200 200

7
a) Date of Leaving service

b) Reason for leaving service

c) Certified that the total amount of contribution indicated in this card

i.e. Rs.

0.00

Col 3+Col4 ( c ) has already been remitted in full in EPF A/c No 1 ( Provident Fund contribution A/c) and in A/c no. 10 ( Pension Fund Contribution account vide note below )

Certified That the difference between the total of the contribution shown under the columns (3) & (4) of the above table and that arrived at on the total Wages shown in Column (2) at the Prescribed rate is solely due to the rounding off of the contributions to the nearest rupee under the rule. *Contribution for the month of March paid in April
*IN THE CASE OF AN EMPLOYEE WHO HAS LEFT THE SERVICE OF THE COMPANY EARLIER, HIS CONTRIBUTION HAS BEEN SHOWN IN THE SUBSEQUENT MONTH WHICH HIS FINAL SETTLEMENT OF SALARY HAS BEEN MADE.

Date : Note: 1 ) In respect of the Form (3A) 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 certificate as shown in the Remarks Column should be added. Note: 2 ) If there is no period of NCS, the word "NIL" to be mentioned against the total column. Note: 3 ) Wherever no wages are shown against any month the period should be shown as NCS
Under Col. 6.

Signature of Employer (Office Seal)