FORM-3A ( Revised )

THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 AND THE EMPLOYEES PENSION SCHEME, 1995
( Paras 35 and 42 ) and ( Parea 19 )
1. Account no.

2. Name / Surname

3. Fathers / Husbands Name

4. Name & Address of the Factory /

Establishment

5. Statutory Rate of PF Contribution :

6. Voluntary Higher rate of employees contribution, if any :
Certified that the total amount of contributions ( both shares ) indicated in this Card, i.e. Rs __________ has
already been remitted in full in EPF A/c No.1 and Pension A/c no. 10 Rs ________.
Certified that the difference between the total of the contribution shown under Columns 3 and 4(a) and 4 (b) of the
table and that arrived at on the total wages shown in column 2 at the prescribed rate is solely due to rounding off of
contribution to the nearest rupee under the rules.

Month

Amount of
Wages

Workers
Share
E.P.F.

Employers Share
E.P.F.
PENSION
Difference
FUND
Refund of
between
Contribution Advance
12% &
8.33%
8.33%
4(a)
4(b)
5

No. of days
of non
contributing
service
6

Remarks
7

Dated: _____________ For __________________________

AUTHORISED SIGNATORY