FORM 5A (For Unexempted Establishments Only) THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952 See paragraph 36A THE EMPLOYEES’ FAMILY PENSION SCHEME, 1971 See paragraph 16 AND THE EMPLOYEES’ DEPOSIT-LINKED INSURANCE SCHEME, 1976 See paragraph 1 Return of Ownership to be sent to the Regional Commissioner 1. | Name of the Establishment........................................................................................................................ | 2. | Code Number of the establishment under the Employees’ Provident Funds and Miscellaneous Provisions Act, 1952 ……………………………………………… | 3. | Postal address of the establishment and its branches/departments, if any...................... | 4. | Industry or business in which engaged............................................................................................. | 5. | Date of first commencement of production/business (Trial/regular)............................... | 6. | Date of closure by the previous management................................................................................. | 7. | Whether run by the owners or lessees (if by lessees, period of the lease should be indicated).......................... |
8. Particulars of owners Name | Age | Status | Father’s name | Residential address | Date of from which in possession | (a) | (b) | (c) | (d) | (e) | (f) | (i) | (ii) | (iii) |
Whether proprietor, Partner, g. Partner, G. Director, Director, etc. 9. If on lease, Particulars of lessees: Name | Age | Father’s name | Residential address | Date of from which in possession | (a) | (b) | (c) | (d) | (e) | (i) | (ii) | (iii) |
10. If registered under the Factories Act, particulars of the Manager/occupier, Name | Age | Father’s name | Residential address | Date of from which in possession | (a) | (b) | (c) | (d) | (e) | A. | Occupier | B. | Manager | | | | | | |
11. Particulars of the persons mentioned above, who are in charge of, and responsible for, the conduct of, the business of the establishment Name | Age | Father’s name | Residential Address | (a) | (b) | (c) | (d) | (i) | | | | (ii) | | | | (iii) | | | |
Dated………….20………. | Signature of employer. | | Designation. | | Seal of the establishment |
Note: Any change in the information given above should be intimated, in writing, to the Regional Commissioner within fifteen days of such change by registered post and in the prescribed manner. | 
