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<title>EMPLOYEES' PROVIDENT FUND ORGANISATION</title>
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<table width="100%" border="0" align="center" cellpadding="0" cellspacing="0">
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    <td><table width="990" border="0" align="center" cellpadding="0" cellspacing="0">
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        <td width="353" class="text-wdthout-pad">(COMBINED CHALLAN OF A/C No. 1,2,10,21 &amp; 22)</td>
        <td width="373" align="left" class="text">(USE SEPARATE CHALLAN FOR EACH MONTH)</td>
        <td width="264" align="right" class="text"><strong>DUPLICATE</strong></td>
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    </table></td>
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  <tr>
    <td align="center" class="text1">STATE BANK OF INDIA</td>
  </tr>
  <tr>
    <td align="center" class="text2">EMPLOYEES' PROVIDENT FUND ORGANISATION</td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td><table width="990" border="0" align="left" cellpadding="0" cellspacing="0">
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        <td width="201" class="text">Establishment Code No. DL :</td>
        <td width="168"><input type="text" id="textfield" name="textfield" /></td>
        <td width="147" class="text">Account Group No. :</td>
        <td width="158"><input type="text" id="textfield" name="textfield" /></td>
        <td width="172" class="text">Paid by Cheque/Cash :</td>
        <td width="144"><input type="text" id="textfield" name="textfield" /></td>
        </tr>
    </table></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td><table width="990" border="0" cellspacing="0" cellpadding="0">
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        <td width="158" class="text">Dues for the Month of :</td>
        <td width="431" align="center" valign="top"><table width="400" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td>&nbsp;</td>
            <td align="center" valign="top" class="text-wdthout-pad">M</td>
            <td align="center" valign="top" class="text-wdthout-pad">M</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
          </tr>
          <tr>
            <td width="134" class="text">Employees Share :</td>
            <td width="51" align="center" valign="top"><input style="width:25px" type="text" id="textfield2" name="textfield2" /></td>
            <td width="37" align="center" valign="top"><input style="width:25px" type="text" id="textfield3" name="textfield3" /></td>
            <td width="65" align="center" valign="top"><input style="width:25px" type="text" id="textfield4" name="textfield4" /></td>
            <td width="37" align="center" valign="top"><input style="width:25px" type="text" id="textfield5" name="textfield5" /></td>
            <td width="34" align="center" valign="top"><input style="width:25px" type="text" id="textfield6" name="textfield6" /></td>
            <td width="42" align="center" valign="top"><input style="width:25px" type="text" id="textfield7" name="textfield7" /></td>
          </tr>
          <tr>
            <td height="5"></td>
            <td height="5" align="center" valign="top"></td>
            <td height="5" align="center" valign="top"></td>
            <td height="5" align="center" valign="top"></td>
            <td height="5" align="center" valign="top"></td>
            <td height="5" align="center" valign="top"></td>
            <td height="5" align="center" valign="top"></td>
          </tr>
          <tr>
            <td class="text">Employer Share :</td>
            <td align="center" valign="top"><input style="width:25px" type="text" id="textfield2" name="textfield2" /></td>
            <td align="center" valign="top"><input style="width:25px" type="text" id="textfield3" name="textfield3" /></td>
            <td align="center" valign="top"><input style="width:25px" type="text" id="textfield4" name="textfield4" /></td>
            <td align="center" valign="top"><input style="width:25px" type="text" id="textfield5" name="textfield5" /></td>
            <td align="center" valign="top"><input style="width:25px" type="text" id="textfield6" name="textfield6" /></td>
            <td align="center" valign="top"><input style="width:25px" type="text" id="textfield7" name="textfield7" /></td>
            </tr>
        </table></td>
        <td width="401"><table width="400" border="0" align="center" cellpadding="0" cellspacing="0">
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            <td>&nbsp;</td>
            <td align="center" valign="top" class="text-wdthout-pad">D</td>
            <td align="center" valign="top" class="text-wdthout-pad">D</td>
            <td align="center" valign="top" class="text-wdthout-pad">M</td>
            <td align="center" valign="top" class="text-wdthout-pad">M</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            <td align="center" valign="top" class="text-wdthout-pad">Y</td>
            </tr>
          <tr>
            <td width="115" class="text-wdthout-pad">Date of Payment :</td>
            <td width="25" align="center" valign="top"><input style="width:25px" type="text" id="textfield8" name="textfield8" /></td>
            <td width="46" align="center" valign="top"><input style="width:25px" type="text" id="textfield9" name="textfield8" /></td>
            <td width="43" align="center" valign="top"><input style="width:25px" type="text" id="textfield10" name="textfield8" /></td>
            <td width="34" align="center" valign="top"><input style="width:25px" type="text" id="textfield11" name="textfield8" /></td>
            <td width="32" align="center" valign="top"><input style="width:25px" type="text" id="textfield12" name="textfield8" /></td>
            <td width="35" align="center" valign="top"><input style="width:25px" type="text" id="textfield13" name="textfield8" /></td>
            <td width="32" align="center" valign="top"><input style="width:25px" type="text" id="textfield12" name="textfield8" /></td>
            <td width="35" align="center" valign="top"><input style="width:25px" type="text" id="textfield13" name="textfield8" /></td>
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        </table></td>
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    </table>                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    </td>
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  <tr>
    <td>&nbsp;</td>
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  <tr>
    <td align="center" valign="top"><table width="990" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td class="text">Total No. of Subscribers :</td>
        <td>&nbsp;</td>
        <td><input style="width:140px" type="text" id="textfield14" name="textfield9" /></td>
        <td>&nbsp;</td>
        <td><input style="width:140px" type="text" id="textfield16" name="textfield11" /></td>
        <td>&nbsp;</td>
        <td><input style="width:140px" type="text" id="textfield18" name="textfield13" /></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td class="text-wdthout-pad">A/c 1</td>
        <td>&nbsp;</td>
        <td class="text-wdthout-pad">A/c 10</td>
        <td>&nbsp;</td>
        <td class="text-wdthout-pad">A/c 21</td>
        <td>&nbsp;</td>
      </tr>
      <tr>
        <td width="206" class="text">Total Wages Due :</td>
        <td width="40">&nbsp;</td>
        <td width="213"><input style="width:140px" type="text" id="textfield15" name="textfield10" /></td>
        <td width="59">&nbsp;</td>
        <td width="222"><input style="width:140px" type="text" id="textfield17" name="textfield12" /></td>
        <td width="53">&nbsp;</td>
        <td width="197"><input style="width:140px" type="text" id="textfield19" name="textfield14" /></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td><table style="border:1px solid #cccccc;" width="990" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="77" rowspan="2" align="center" class="text">Sl. No.</td>
        <td width="195" rowspan="2" align="left" class="text-wdthout-pad">PARTICULARS</td>
        <td width="116" align="center" valign="top" class="text-wdthout-pad">A/c. No. 1</td>
        <td width="117" align="center" valign="top" class="text-wdthout-pad">A/c. No. 2</td>
        <td width="117" align="center" valign="top" class="text-wdthout-pad">A/c. No. 10</td>
        <td width="117" align="center" valign="top" class="text-wdthout-pad">A/c. No. 21</td>
        <td width="117" align="center" valign="top" class="text-wdthout-pad">A/c. No. 22</td>
        <td width="132" align="center" valign="top" class="text-wdthout-pad">Total</td>
      </tr>
      <tr>
        <td colspan="6" align="center" valign="top" class="text-wdthout-pad">.........AMOUNT (in Rupees).......</td>
        </tr>
    </table></td>
  </tr>
  <tr>
    <td align="center" valign="top"><table width="990" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="66" align="center" class="text">1.</td>
        <td width="198" class="text-wdthout-pad">Employer's Share of Cont.</td>
        <td width="126" align="center"><input style="width:110px" type="text" id="textfield20" name="textfield15" /></td>
        <td width="117" align="center"><input style="width:110px" type="text" id="textfield21" name="textfield16" /></td>
        <td width="120" align="center"><input style="width:110px" type="text" id="textfield22" name="textfield17" /></td>
        <td width="119" align="center"><input style="width:110px" type="text" id="textfield23" name="textfield18" /></td>
        <td width="117" align="center"><input style="width:110px" type="text" id="textfield24" name="textfield19" /></td>
        <td width="127" align="center"><input style="width:110px" type="text" id="textfield25" name="textfield20" /></td>
      </tr>
      <tr>
        <td align="center" class="text">2.</td>
        <td class="text-wdthout-pad">Employer's Share of Cont.</td>
        <td align="center"><input style="width:110px" type="text" id="textfield20" name="textfield15" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield21" name="textfield16" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield22" name="textfield17" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield23" name="textfield18" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield24" name="textfield19" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield25" name="textfield20" /></td>
        </tr>
      <tr>
        <td align="center" class="text">3.</td>
        <td class="text-wdthout-pad">ADM. Charges</td>
        <td align="center"><input style="width:110px" type="text" id="textfield20" name="textfield15" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield21" name="textfield16" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield22" name="textfield17" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield23" name="textfield18" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield24" name="textfield19" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield25" name="textfield20" /></td>
        </tr>
      <tr>
        <td align="center" class="text">4.</td>
        <td class="text-wdthout-pad">Insp. Charges</td>
        <td align="center"><input style="width:110px" type="text" id="textfield20" name="textfield15" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield21" name="textfield16" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield22" name="textfield17" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield23" name="textfield18" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield24" name="textfield19" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield25" name="textfield20" /></td>
        </tr>
      <tr>
        <td height="31" align="center" class="text">5.</td>
        <td class="text-wdthout-pad">Penal Damages</td>
        <td align="center"><input style="width:110px" type="text" id="textfield20" name="textfield15" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield21" name="textfield16" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield22" name="textfield17" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield23" name="textfield18" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield24" name="textfield19" /></td>
        <td align="center"><input style="width:110px" type="text" id="textfield25" name="textfield20" /></td>
        </tr>
      <tr>
        <td align="center" valign="top" class="text">6.</td>
        <td valign="top" class="text-wdthout-pad">Misc. Payment (past Accumulations only)</td>
        <td align="center" valign="top"><input style="width:110px" type="text" id="textfield20" name="textfield15" /></td>
        <td align="center" valign="top"><input style="width:110px" type="text" id="textfield21" name="textfield16" /></td>
        <td align="center" valign="top"><input style="width:110px" type="text" id="textfield22" name="textfield17" /></td>
        <td align="center" valign="top"><input style="width:110px" type="text" id="textfield23" name="textfield18" /></td>
        <td align="center" valign="top"><input style="width:110px" type="text" id="textfield24" name="textfield19" /></td>
        <td align="center" valign="top"><input style="width:110px" type="text" id="textfield25" name="textfield20" /></td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
        <td>&nbsp;</td>
      </tr>
      <tr>
        <td>&nbsp;</td>
        <td align="right" class="text">Total</td>
        <td align="right"><input style="width:117px" type="text" id="textfield26" name="textfield21" /></td>
        <td align="left"><input style="width:117px" type="text" id="textfield27" name="textfield22" /></td>
        <td align="left"><input style="width:117px" type="text" id="textfield28" name="textfield23" /></td>
        <td align="left"><input style="width:117px" type="text" id="textfield29" name="textfield24" /></td>
        <td align="left"><input style="width:117px" type="text" id="textfield30" name="textfield25" /></td>
        <td align="left"><input style="width:117px" type="text" id="textfield31" name="textfield26" /></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td><table width="730" border="0" align="right" cellpadding="0" cellspacing="0">
      <tr>
        <td width="119" class="text-wdthout-pad">Amount in words</td>
        <td width="345" align="left"><input style="width:300px" type="text" id="textfield33" name="textfield28" /></td>
        <td width="136" class="text-wdthout-pad">For Banks use only</td>
        <td width="130"><input style="width:130px" type="text" id="textfield32" name="textfield27" /></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td><table width="990" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="600" valign="top"><table width="600" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="200" align="left" valign="top" class="text-wdthout-pad">Name of Establishment :</td>
            <td width="400" align="left" valign="top"><input style="width:400px" type="text" id="textfield34" name="textfield29" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Address:</td>
            <td align="left" valign="top"><input style="width:400px" type="text" id="textfield35" name="textfield30" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Name of Dipositor :</td>
            <td align="left" valign="top"><input style="width:400px" type="text" id="textfield36" name="textfield31" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Signature of the Depositor :</td>
            <td align="left" valign="top"><input style="width:400px" type="text" id="textfield37" name="textfield32" /></td>
          </tr>
          </table></td>
        <td width="390" align="right" valign="top"><table width="300" border="0" align="right" cellpadding="0" cellspacing="0">
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Amount Received Rs. :</td>
            <td align="left" valign="top"><input style="width:130px" type="text" id="textfield38" name="textfield33" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">For Cheques only :</td>
            <td align="left" valign="top"><input style="width:130px" type="text" id="textfield39" name="textfield34" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Date of Presentation :</td>
            <td align="left" valign="top"><input style="width:130px" type="text" id="textfield40" name="textfield35" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Date of Realisation :</td>
            <td align="left" valign="top"><input style="width:130px" type="text" id="textfield41" name="textfield36" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Branch Name :</td>
            <td align="left" valign="top"><input style="width:130px" type="text" id="textfield42" name="textfield37" /></td>
          </tr>
          <tr>
            <td align="left" valign="top" class="text-wdthout-pad">Branch Code No. :</td>
            <td align="left" valign="top"><input style="width:130px" type="text" id="textfield43" name="textfield38" /></td>
          </tr>
          <tr>
            <td width="169" align="left" valign="top">&nbsp;</td>
            <td width="131" align="left" valign="top">&nbsp;</td>
          </tr>
        </table></td>
      </tr>
    </table></td>
  </tr>
  <tr>
    <td align="center" valign="top" class="text1"><strong>(TO BE FILLED IN BY EMPLOYER)</strong></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td><table width="990" border="0" cellspacing="0" cellpadding="0">
      <tr>
        <td width="125" class="text-wdthout-pad">Name of the Bank</td>
        <td width="323"><input style="width:280px" type="text" id="textfield44" name="textfield39" /></td>
        <td width="86" class="text-wdthout-pad">Cheque No.</td>
        <td width="324" class="text-wdthout-pad"><input style="width:280px" type="text" id="textfield45" name="textfield40" /></td>
        <td width="42" class="text-wdthout-pad">Date</td>
        <td width="90"><select style="width:90px;" name="select" id="select">
        <option>01/05/2012</option>
        </select></td>
        </tr>
    </table></td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
  <tr>
    <td>&nbsp;</td>
  </tr>
</table>

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