21

FORM NO. 3-A (Revised)

THE EMPLOYEE'S PROVIDENT FUNDS SCHEME 1952 (Para 35 & 42)
AND
THE EMPLOYEE'S PENSION SCHEME 1995 (Para 19)
CONTRIBUTION CARD FOR THE CURRENCY PERIOD FROM 1ST APRIL 2009 TO 31ST MARCH 2010

1. Account NO.: HR/10730/

1872

5. Name & Address of the Establishment / Factory

M/s SABRINA Plot No.259,Udyog Vihar Phase-I,

2. Name/Surname : MAMTA
JOGINDER SINGH

4. Statutory rate of contribution : 12 %

Month

Worker's Share

6. Voluntary higher rate of employee's contribution if any

Employer's Share
Pension Fund

EPF Difference

Amount of
Wages

EPF

Gurgaon-122016,Haryana

between 12 % - 8.33

8.33 %

4(b)

%(if any) 4(a)

Refund of
Advance

3. Father's / Husband's Name :

of non contributing

No. of days period

Service (if any)

March
Paid in
April

3192

383

117

266

April

3841

461

141

320

May

4139

497

152

345

June

3649

438

134

304

1.5

July

3841

461

141

320

Aug.

1487

178

54

124

19

Sep.

30

Oct.

31

Nov.

30

Dec.

31

Jan.

31

FEB
Paid in
March

28

103

12

20252

2430

742

1688

205.5

Arrear
TOTAL

(Para 35 & 42)

ara 19)

009 TO 31ST MARCH 2010

e Establishment / Factory
Plot No.259,Udyog Vihar Phase-I,

16,Haryana

of employee's contribution if any

Remarks

DATE OF LEAVING
SERVICE

15.08.09
(b) Reason for leaving
service, if any

Resigned

( c) Total Contribution
Both share Rs..
4860.00

has already remited in

full in EPF A/c. No. 1,

FORM 6A (Revised)
( FOR UNEXEMTED ESTABLISHMENT ONLY )

The Employees Provident Fund Scheme, 1952

[ PARAGRAPH 43 ]
AND

The Employees Pension Scheme, 1995

[ PARAGRAPH 20 (4) ]
Annual statement of contribution for the Currency period form 1st April 2009 to 31st March 2010
Name & Address of the Establishment
M/s SABRINA
Statutory rate of Contribution
Plot No.259,Udyog Vihar,Phase-I
Gurgaon,Haryana
Code No. of the Establishment
No. of members voluntarily contributing at a higer rate
HR/ 10730
Employers' Contribution
Wages, retaining
Amount of
allowance (if any)
worker's
& DA including
EPF
Pension
Account
Name of Member
contributions
Sl No.
cash value of
difference Fund
Number
(in block letter)
deducted
food concession
between (EPS)
from the
paid during the
12% &10% 8.33%
wages (EPF)
currency period
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

2
8
203
233
435
852
1525
1741
1742
1771
1773
1820
1853
1854
1855
1863
1864
1865
1866
1869
1870
1872
1873
1874
1875

3
MAQSOOD ALAM
JITENDER KUMAR
TAPAN KUMAR ROY
JAGAT SINGH RAWAL
MD GAYASUDDIN
BHOLA SHANKER
SHRI KRISHAN
RAJESH KUMAR
PRITTI
KAMAL SIMGH
SHEZAD ALAM
MANJU DEVI
BABY
RANI
NARENDRA
RAM ASHISH KUMAR
NAGENDER RAM
SANJAY KUMAR
AMRENDRA
GUDDU
MAMTA
NEELAM
KHUSHBOO
AJAY PRASAD

5
50547
38977
48301
48653
50741
48441
1182
49109
14909
21807
1205
1064
1064
2837
1205
1205
1205
1205
2093
10211
20252
2837
1064
2956

6066
4677
5798
5839
6089
5814
142
5894
1789
2618
145
128
128
340
145
145
145
145
251
1225
2430
340
128
355

6
1858
1428
1771
1781
1863
1780
43
1806
547
801
44
39
39
104
44
44
44
44
77
375
742
104
39
108

7
4208
3249
4027
4058
4226
4034
99
4088
1242
1817
101
89
89
236
101
101
101
101
174
850
1688
236
89
247

25
26
27
28
29
30
31
32

1878
1879
1886
1887
1892
1894
1910
1913

33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63

1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944

KARU
ARJUN KUMAR
SUCHETA
MANJU DEVI
BABY
POONAM
KIRAN
DHIR PAL
JITANDRA KUMAR
CHAURASIA
RAM PARVESH SAW
RANGESH
KARU
PRAVEENA
SHAILENDRA PRASAD
BANU
NEELAM
KARU
KAMAL SIMGH
GORE LAL
BABY DEVI
SHILA NATH MISHRA
UCHIT KUMAR
SANJU DEVI
NISHU
MUKESH KUMAR
RADHA
MANJU DEVI
MAHESH NARAYAN
ABHEY KUMAR
NARENDRA
SATENDER PRASAD
DHIRAJ KUMAR
SANJU DEVI
LALITA DEVI
RAKESH YADAV
SANTOSH KUMAR
RAJ KUMAR
GUDDU
VINEETA DEVI
TOTAL=>

4486
9023
1064
21758
946
1064
1064
42971

539
1084
128
2611
114
128
128
5156

164
332
39
798
35
39
39
1577

375
752
89
1813
79
89
89
3579

35962
9142
7271
2850
4925
21570
19408
1515
17226
19332
2916
11335
9327
3995
3943
3807
4308
6832
8814
3671
3671
8616
7826
3714
2855
2991
2991
2991
6457
6520
3161
755388

4317
1097
872
342
591
2590
2329
182
2068
2319
350
1361
1120
479
473
457
517
819
1058
440
440
1034
939
446
342
359
359
359
775
782
379
90659

1321
335
266
105
181
792
712
56
633
710
107
417
343
146
145
139
159
250
324
134
134
316
287
137
104
110
110
110
238
239
116
27724

2996
762
606
237
410
1798
1617
126
1435
1609
243
944
777
333
328
318
358
569
734
306
306
718
652
309
238
249
249
249
537
543
263
62935

FORM 6A (Revised)

12%

NIL

Remarks

Sl No.

Month

Reconciliation of Remittances for the Year 2009-2010

Pension
EPF Contributions
Fund
Administration Charges Rs.
including refund of Contributi
DLI
EDLI Adm.
advaces A/c No.1 ons A/c Adm. Charges Contribution Charges A/c
A/c No. 2
No. 10
A/c No. 21
No. 22

Mar-09 Paid
in Apr-09
May-09
Jun-09

Jul-09

8864

4712

622

283

Aug-09

9789

5201

687

312

Sep-09

483

220

6877
4567

3657

Oct-09

2425

320

146

Nov-09

7153

3801

502

228

Dec-09

8181

4349

574

261

10

Jan-10

9684

5150

680

309

11

Feb-10

17874

9502

1255

570

11

14180

7538

995

452

241

127

17

1223
118383

649
62935

86
8309

39
3778

1
75

1
2

Feb-10 Paid
in Mar-10
12
Arrear July13 09 to Aug.09
14
Total

Arrear Jan.10

12559

6683

881

401

8774
8417

4664

616

280

4477

591

269

(i) Total Number of contribution cards enclosed (Form 3A

63

(ii) Certified that form 3A duly completed, of all the members listed in this statement are enclosed. The Form
3A already sent during the course of currency period for the final settlement of the concerned members' account vide
'Remarks' furnished against the name of the respective members above, are also enclosed.

_______________________________
Signature of Employer (with office seal)

NOTE :1. The names of all members, including those who had left service during the currency perriod, should be
included in this statement. Where the Form 3-A in respect o such members had left sevice, the fact
should be stated against the members in the 'Remarks' column.
2. In case of substantial variation in the wages/contributions of any members as compared to those shown
in previous months statement, the reason should be explained adequately in the 'Remarks' column.
3. In respect o those members who have not opted fo Pension Fund their entire employers contribution

@10% or 12% as the case may be shown under column No.6

Date of
Payment

17-Apr-09
14-May-09
16-Jun-09
16-Jul-09
21-Aug-09
14-Sep-09
21-Oct-09
21-Nov-09
19-Dec-09
25-Jan-10
22-Feb-10
31-Mar-10
21-Oct-09
31-Mar-10

are enclosed. The Form

ed members' account vide
d.

__________________
ployer (with office seal)

ncy perriod, should be

eft sevice, the fact

mpared to those shown

'Remarks' column.
ployers contribution