yrajesh34

rajumehta
Form 3 – A (Revised)
(For unexempted Establishments only)

The Employees’ Provident Funds Scheme, 1952

(See paragraphs 35 & 42)

Contribution Cad for the currency period From 1st , 19 to 30th/31st , 19

1. Account No.
2. Name /Surname

(in block capitals)

3. Father’s / Husband’s Name
4. Name & Address of the Factory/Establishment
5. Statutory rate of the Contribution
6. Voluntary higher rate of employee’s contribution, if any

Contributions
Amount of Worker’s Share Employer’s Share Break in Rem
Wages membersh arks
E.P.F. R.P.F Total E.P.F. R.P.F. Total Refund
ip/reckona
. of
ble
advanc
service
e

(1) (2) (3) (4) (5) (6)

Months
April 19

May 19

June 19

July 19

August 19
 September 19

October 19

November 19

December 19

January 19

February 19

March 19

Total

(a) Date of leaving service

(b) Reason for leaving service
(c) Certified that the total amount of contributions (both shares) indicated in this card i.e.
Rs. [Column (3)(c)] [Column (4)(c)] has already been remitted in full in
EPF A/c No. 1 (P.F.A/c) and A/c No. 10 (E.P.F. A/c.) (vide note below).

Certified that the difference between the total of the contribution shown under Cols. 3 & 4
of the above table and that arrived at one the total wages shown in Column 2 at the
prescribed rate is solely due to rounding off of contributions to the nearest rupee under
the rules.

Dated 19 Signature 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 ‘Remarks’ columns should be added.
 Form 6-A
The Employees’ Provident Funds Scheme, 1952
[See Paragraph 38(3)]

Consolidated Annual Contribution Statement

Annual statement of contribution for the currency period

from 1st 19 to 19

Statutory rate of contribution

No. of Members voluntarily subscribing at a higher rate
Name and address of the Factory/Establishment
Code No. of the Establishment

Sl. Account Name of the Member (in block Wages, Retaining allowance (if
No. No. letters) any) and D.A. including cash
value of food concession paid
during the currency period
1 2 3 4

Worker’s Employer’s Contribution Refund of Rate of remarks

Contribution Advances higher
voluntary
contribution
(if any)

5 6 7 8 9

Total Rs. Rs.

 Admn. Charges Rs. Aggregate of Cols.
(at 0.3% of wages) (5)+ (6)+ (7)
Rs. contributions:

Reconciliation of remittances
Sl. Month Amount remitted to Admn. Charges
No. contributions (including
refund of advances) Account No. 2
Account No. 1
1 Rs. Rs.
2 Rs. Rs.
3 Rs. Rs.
4 Rs. Rs.
5 Rs. Rs.
6 Rs. Rs.
7 Rs. Rs.
8 Rs. Rs.
9 Rs. Rs.
10 Rs. Rs.
11 Rs. Rs.
12 Rs. Rs.

Certified that the difference between the figures of total contributions and Admn. Charges
remitted during the currency period and those shown under Columns (4) to (7) above is
solely due to the rounding off of the amounts to the nearest rupee/5 paise under the rules

Signature of employer with office seal

(1) Total number of contribution cards enclosed (form 3-A)

(2) Certified that the Form 3-A, duly completed, of all the members listed in this statement
are enclosed except those already sent during the course of the currency period for
the final settlement of the concerned members’ accounts vide ‘Remarks’ furnished
against the names of the respective members above.

Signature of employer