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EMPLOYEES' STATE INSURANCE CORPORATION

Challan Form for Deposit in A/C No. 1


Date Month Year

EMPLOYEES' STATE INSURANCE CORPORATION


Challan Form for Deposit in A/C No. 1
0 Date Month Year

Employer's Code Name of Factory/Estt. & Address

Bank & Branch Code

Employer's Code Name of Factory/Estt. & Address

Bank & Branch Code 0 0 0 Cash .. Cheque *. D.D. .. Dated Period of Contribution
0

Mode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Details of Payment [Tick (p ) mode used] No. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total 0

Cash .. Cheque *. D.D. .. Dated Period of Contribution

Mode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Details of Payment [Tick (p ) mode used] No. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total

Regular Contribution. Interest Damages .. Others

Regular Contribution. Interest Damages .. Others

Total Wages

0 0 0

Total Wages

Total amount (in words) #R.O. Demand Letter No. & Date

Total amount (in words) #R.O. Demand Letter No. & Date

Signature __________________________________________ Name & Designation - Seal of Authorised Signatory

Signature __________________________________________ Name & Designation - Seal of Authorised Signatory

(Acknowledgment) (to be filled by Depositor) Received Rs. (Rs. ______________________________________________ Only) In Cash/by Cheque/DD No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 For use in Bank Bank Scroll No. . Dated .. Authorised Signature & Seal of the Receiving Bank (to be filled by Depositor)

(Acknowledgment) For use in Bank Bank Scroll No. . Dated .. Authorised Signature & Seal of the Receiving Bank

Received Rs. (Rs. ______________________________________________ Only) In Cash/by Cheque/DD No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1

EMPLOYEES' STATE INSURANCE CORPORATION


Challan Form for Deposit in A/C No. 1
Date .. M onth Year

EMPLOYEES' STATE INSURANCE CORPORATION


Challan Form for Deposit in A/C No. 1
0 .. Date M onth Year

Employer's Code

Bank & Branch Code

Employer's Code

Bank & Branch Code 0 0 0 Cash .. Cheque *. D.D. .. Dated Period of Contribution

Name of Factory/Estt. & Address

Name of Factory/Estt. & Address

M ode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Details of Payment [Tick (p ) mode used] No. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total 0

Cash .. Cheque *. D.D. .. Dated Period of Contribution


JANUARY 2009

M ode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Details of Payment [Tick (p ) mode used] No. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total

Regular Contribution. Interest Damages .. Others

Regular Contribution. Interest Damages .. Others

Total Wages

0 0 0

Total Wages

Total amount (in words) #R.O. Demand Letter No. & Date

Total amount (in words) #R.O. Demand Letter No. & Date

S ignature __________________________________________ Name & Designation - Seal of Authorised Signatory

S ignature __________________________________________ Name & Designation - Seal of Authorised Signatory

(Acknowledgment) (to be filled by Depositor) Received Rs. (Rs. ______________________________________________ Only) In Cash/by Cheque/DD No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 For use in Bank Bank Scroll No. . Dated .. Authorised Signature & Seal of the Receiving Bank (to be filled by Depositor)

(Acknowledgment) For use in Bank Bank Scroll No. . Dated .. Authorised Signature & Seal of the Receiving Bank

Received Rs. (Rs. ______________________________________________ Only) In Cash/by Cheque/DD No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1