Form-A

See rule 12 (4)

Statement showing the Particulars of contribution amounts paid to

The Secretary, Tamil Nadu Labour Welfare Board, Chennai-600 006
For the Year ending : 31.12.2022

Sterling Holiday Resorts Ltd, #73, Kundah House

Name and address of the establishment Account No.
Road, Fern Hill, Ooty - 643004

No of Persons who are No of Persons From No of Persons from Amount of Amount of

Excluded Whom recovery whom employees Employees Employers
Total No of employees from the Payment of not Made for any other contributions have been Contribution Rs.20/- Contribution Rs.40/- Total Amount remitted
In the Establishment Contribution reason recovered Per head Per head DD No.___Date____
(1) (2) (3) (4) (5) (6) (7)

110 Nil Nil 110 2200 4400 6600

Signature of the Employers

For Sterling Holiday Resorts Ltd ,

Authorised Person

1.Certified That the Number employes shown column (1) is correct as per the muster roll / Attendance register 2.
Cerfied that the contribution are paid in respect of all employees covered by the Act