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1. Details of establishment :

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  (a)  Name of the establishment with full address :

..................................................................

  (b)  Code No. allotted by the employees provident fund organisation :

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2. Details of employees (include all branches/units, etc.) :

  (a)  No. of employees as at the end of previous month :

  (b)  No. of employees who joined during the month :

  (c)  No. of employees who left service during the month :

  (d)  No. of employees as at the end of the month :

        (a) + (b) – (c)

  (e)  Out of (d) above, No. of excluded employees :

  (f)  No. of pension fund members as at the end of the month Please furnish the above mentioned details unit-wise situated at different places.

Attach separate sheet, if necessary :

3. Constitution of board of trustees :

  (a)  Date on which the present board was constituted :

D

D

M

M

Y

Y

Y

Y

  (b)  Its term : Years

  (c)  Total number of trustees :

   (i)  Employees’ representatives :

  (ii)  Employer’s representatives :

4. Wages, contributions, etc. :

  (a)  Amount of gross wages liable to pension contribution :

Rs.

  (b)  Rate of contribution to pension fund

%

  (c)  Amount of pension contribution to be transferred for

Rs.

        the current month :

  (d)  Amount of arrears due, if any, for transfer to the board

        of trustees at the end of the previous month :

Rs.

  (e)  Total of (c) & (d) :

Rs.

  (f)  Amount actually transferred to the board of trustees :

Rs.

  (g)  Balance due, if any, for transfer to the board of trustees

Rs.

        (e) - (f) :

  (h)  Whether the interest payable under section 7Q of the

        Act for the belated transfer of funds, if any, has been

        Paid?

Yes

No

   (i)  Amount of interest still payable at the end of the month:

Rs.

5. Details of pensioners

  (a)  No. of pensioners at the end of the month :

   (i)  Member (self) pensioners :

  —  Superannuation pension :

  —  Early pension :

  —  Disablement pension :

  (ii)  Spouse pensioners :

  —  Death in service :

  —  Death away from service :

  —  Death as pensioner :

(iii)  Children pensioner :

  —  Normal children :

  —  Disabled children :

        (life-long pension)

(iv)  Orphan pensioner :

  (v)  Nominee pensioner :

(vi)  Dependent parents pensioner :

  (b)  Total amount of pension paid during the month :

6. Details of exit cases :

  (a)  No. of persons who have taken withdrawal benefit

        during the month :

  (b)  Amount paid during the month :

Rs.

        No. of exit cases where scheme certificate has been

        Issued

7. Details of investment :

  (a)  Amount lying invested in the pension fund in the

        beginning of the month :

Rs.

  (b)  Amount received during the month :

   (i)  By way of contribution from the employer :

        Current month :

Rs.

        Arrears, if any :

Rs.

  (ii)  Encashment of matured securities/deposits :

Rs.

(iii)  Interest/dividend on investments :

Rs.

(iv)  Other transfer-in-cases :

Rs.

  (v)  Damages, if any :

Rs.

(vi)  Interest on belated payments, if any :

Rs.

(vii)  Miscellaneous, if any (please specify) :

Rs.

  (c)  Payments made during the month :

Rs.

  (d)  Amount invested during the month :

        Securities :

  —  Central Government :

Rs.

  —  State Governments :

Rs.

  —  Others, if any :

Rs.

        Deposits:

  —  Public financial institutions/banks :

Rs.

  (e)  Whether pattern of investment followed :

Yes

No

  (f)  If so, classify the percentage :

   (i)  Securities :

  —  Central Government :

%

  —  State Governments :

%

  —  Others, if any :

%

  (ii)  Deposits :

  —  Public financial institutions/banks :

%

(iii)  Annuity purchased from LIC :

Rs.

  (g)  Amount lying uninvested in cash/bank :

Rs.

8. Mode of disbursement ü Tick one :

  —  Through bank :

  —  Through post offices :

  —  Through LIC by purchase of annuity :

  —  Others, if any (please specify) :

9. Rules of establishment’s pension fund :

Details of amendment, if any carried out during the month to make the rules at par with the statutory Pension Scheme (Employees’ Pension Scheme, 1995)

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Date: .......................

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Signature with official seal of the employer/trustees of the board