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<title>EMPLOYEES' PROVIDENT FUND MISCLLANEOUS PROVISIONS ACT,1952</title>
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    <td><table width="100%" border="0" align="center" cellpadding="0" cellspacing="0">
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        <td width="303" class="text-wdthout-pad">Only for Un-Exempted Establishments</td>
        <td width="347" align="center" valign="top" class="text"><strong>Form 12-A (Revised)</strong></td>
        <td width="340" align="right" class="text">(To be filled in by the EPFO)</td>
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  <tr>
    <td align="center" class="text1"><strong>Employees ' Provident Fund and miscllaneous Provisions Act, 1952</strong>
    </td>
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    <td align="center" class="text2">Employees' Pension Scheme, 1995</td>
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  <tr>
    <td align="center" valign="top"><table width="990" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="350" align="left" class="text-wdthout-pad">Name and address of the Establishment</td>
        <td width="331" align="center" class="text-wdthout-pad">[Paragraph 20 (4)]</td>
        <td width="309" align="right" valign="top"><table width="250" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="150" class="text-wdthout-pad">Establishment Status</td>
            <td width="35">&nbsp;</td>
            <td width="33">&nbsp;</td>
            <td width="32"><input style="width:25px;" type="text" name="textfield" id="textfield" /></td>
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          <tr>
            <td class="text-wdthout-pad">Group Code</td>
            <td><input style="width:25px;" type="text" name="textfield2" id="textfield2" /></td>
            <td><input style="width:25px;" type="text" name="textfield3" id="textfield3" /></td>
            <td><input style="width:25px;" type="text" name="textfield4" id="textfield4" /></td>
          </tr>
          </table></td>
      </tr>
      <tr>
        <td><table width="330" border="0" cellspacing="0" cellpadding="0">
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            <td align="left" valign="top" class="text-wdthout-pad">M/s</td>
            <td><input style="width:250px; height:50px" type="text" name="textfield5" id="textfield5" /></td>
            </tr>
          <tr>
            <td height="8" align="left"></td>
            <td height="8"></td>
            </tr>
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            <td width="62" align="left" class="text-wdthout-pad">Code No.</td>
            <td width="268"><span class="text-wdthout-pad">
              <input style="width:25px;" type="text" name="textfield18" id="textfield18" />
              </span><span class="text-wdthout-pad">
                <input style="width:25px;" type="text" name="textfield19" id="textfield19" />
                </span><span class="text-wdthout-pad">
                  <input style="width:25px;" type="text" name="textfield20" id="textfield20" />
                  </span><span class="text-wdthout-pad">
                  <input style="width:25px;" type="text" name="textfield21" id="textfield21" />
                  </span><span class="text-wdthout-pad">
                  <input style="width:25px;" type="text" name="textfield22" id="textfield22" />
                  </span><span class="text-wdthout-pad">
                  <input style="width:25px;" type="text" name="textfield23" id="textfield23" />
                  </span><span class="text-wdthout-pad">
                  <input style="width:25px;" type="text" name="textfield24" id="textfield24" />
                </span></td>
            </tr>
          </table></td>
        <td align="left" valign="top" class="text-wdthout-pad">Currency Period from 1st April , 200 
          <input style="width:25px;" type="text" name="textfield6" id="textfield6" /> 
          to 31st March 200 
          <input style="width:25px;" type="text" name="textfield7" id="textfield7" /> 
          Statement of contributions for the Month of 
          <input style="width:25px;" type="text" name="textfield8" id="textfield8" />
          <input style="width:25px;" type="text" name="textfield9" id="textfield9" />
          <input style="width:25px;" type="text" name="textfield10" id="textfield10" />
          <input style="width:25px;" type="text" name="textfield11" id="textfield11" />
          <input style="width:25px;" type="text" name="textfield12" id="textfield12" />
          <input style="width:25px;" type="text" name="textfield13" id="textfield13" />
          <br />
          Statutory rate of contributions 
          <input style="width:25px;" type="text" name="textfield14" id="textfield14" />
          <input style="width:25px;" type="text" name="textfield15" id="textfield15" />
          <input style="width:25px;" type="text" name="textfield16" id="textfield16" />
          <input style="width:25px;" type="text" name="textfield17" id="textfield17" /></td>
        <td>&nbsp;</td>
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    <td>&nbsp;</td>
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    <td><table width="100%" border="1" align="center" cellpadding="3" cellspacing="0">
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        <td align="center" class="text-wdthout-pad">Particulars</td>
        <td align="center" class="text-wdthout-pad">Wages on<br />
which Contributions<br />
are Payable</td>
        <td colspan="4" align="center" valign="top"><table width="400" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td colspan="2" align="center" class="text-wdthout-pad">Amount of Contribution</td>
            <td colspan="2" align="center" class="text-wdthout-pad">Amount of Contribution<br /> 
              Remitted</td>
            </tr>
          <tr>
            <td width="116" align="center" class="text-wdthout-pad">Recovered <br />
              from the<br />
Workers</td>
            <td width="116" align="center" valign="top" class="text-wdthout-pad">Payable <br />
              by the<br />Employer</td>
            <td width="116" align="center" valign="top" class="text-wdthout-pad">Worker's<br />
              Share</td>
            <td width="118" align="center" valign="top" class="text-wdthout-pad">Employer's<br />
              Share</td>
          </tr>
        </table></td>
        <td align="center" valign="top" class="text-wdthout-pad">Amount of Administrative<br />
          Charges Due</td>
        <td align="center" valign="top" class="text-wdthout-pad">Amount of Administrative Charges Remitted</td>
        <td align="center" valign="top" class="text-wdthout-pad">Date of Remittance (Enclose Triplicate Copies of Challan)</td>
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        <td align="center" class="text-wdthout-pad">E.P.F. A/c No. 01</td>
        <td align="center">&nbsp;</td>
        <td width="103" align="center">&nbsp;</td>
        <td align="center">&nbsp;</td>
        <td width="94" align="center">&nbsp;</td>
        <td align="center">&nbsp;</td>
        <td align="center">&nbsp;</td>
        <td align="center">&nbsp;</td>
        <td align="center"><span class="text-wdthout-pad">
          <input style="width:15px;" type="text" name="textfield25" id="textfield25" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield26" id="textfield26" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield27" id="textfield27" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield28" id="textfield28" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield29" id="textfield29" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield30" id="textfield30" />
        </span></td>
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        <td align="center" class="text-wdthout-pad">Pension Fund A/c No. 10</td>
        <td align="center">&nbsp;</td>
        <td align="center" bgcolor="#CCCCCC" class="text-wdthout-pad">NIL</td>
        <td align="center">&nbsp;</td>
        <td align="center" bgcolor="#CCCCCC" class="text-wdthout-pad">NIL</td>
        <td align="center">&nbsp;</td>
        <td align="center" bgcolor="#CCCCCC" class="text-wdthout-pad">NIL</td>
        <td align="center" bgcolor="#CCCCCC" class="text-wdthout-pad">NIL</td>
        <td align="center"><span class="text-wdthout-pad">
          <input style="width:15px;" type="text" name="textfield31" id="textfield31" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield31" id="textfield32" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield31" id="textfield33" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield31" id="textfield34" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield31" id="textfield35" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield31" id="textfield36" />
        </span></td>
      </tr>
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        <td width="86" align="center" class="text-wdthout-pad">D.L.I A/c No. 21</td>
        <td width="108" align="center">&nbsp;</td>
        <td align="center" bgcolor="#CCCCCC" class="text-wdthout-pad">NIL</td>
        <td width="94" align="center">&nbsp;</td>
        <td align="center" bgcolor="#CCCCCC" class="text-wdthout-pad">NIL</td>
        <td width="105" align="center">&nbsp;</td>
        <td width="104" align="center">&nbsp;</td>
        <td width="134" align="center">&nbsp;</td>
        <td width="142" align="center"><span class="text-wdthout-pad">
          <input style="width:15px;" type="text" name="textfield32" id="textfield37" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield32" id="textfield38" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield32" id="textfield39" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield32" id="textfield40" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield32" id="textfield41" />
        </span><span class="text-wdthout-pad">
        <input style="width:15px;" type="text" name="textfield32" id="textfield42" />
        </span></td>
      </tr>
    </table></td>
  </tr>
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    <td><table width="100%" border="1" cellspacing="0" cellpadding="0">
      <tr>
        <td><table width="800" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="164" valign="top" class="text">Total No. of Employees
            <ul class="abc">
            <li>Contract</li>
            <li> Rest</li>
            <li>Total</li>
            </ul>
            
            </td>
            <td width="164"><span class="text-wdthout-pad">
              <input style="width:90px; margin:5px 0px 5px 0px; height:70px" type="text" name="textfield33" id="textfield43" />
            </span></td>
            <td width="166" class="text-wdthout-pad">Name &amp; Address of the <br />
              Bank in which the amount<br />
              is remitted</td>
          </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="center" valign="top"><table width="990" border="1" cellspacing="0" cellpadding="0">
      <tr>
        <td class="text">Details of Subscribers </td>
        <td class="text">E.P.F</td>
        <td class="text">Pension Fund</td>
        <td class="text">E.D.L.I</td>
        <td width="366" rowspan="5" align="center" class="text-wdthout-pad">Signature of the Employer<br />
          with official (Seal)</td>
      </tr>
      <tr>
        <td class="text">No. of Subscribers as per last month</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        </tr>
      <tr>
        <td class="text">No. of New subscribers (vide Form 5)</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        </tr>
      <tr>
        <td class="text">No. of subscribers left service (vide Form 10)</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        </tr>
      <tr>
        <td width="357" class="text">(Nett.) Total No. of Subscriber</td>
        <td width="68">&nbsp;</td>
        <td width="107">&nbsp;</td>
        <td width="80">&nbsp;</td>
        </tr>
    </table></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
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