EMPLOYEES' PROVIDENT FUND ORGANISATION
(Combined Challan for A/c No.1, 2, 10, 21 & 22)

Business No.
For the Month of:
VDR No.: ________________________
(To be filled in by EPFO)
(Amount in Rs.)
Sl.No.
Particulars
A/c No. 1
A/c No.2
A/c No.10
A/c No.21
A/c No.22
Total
Employees' Share
Employer's Share
Total
1 Contribution, Administrative / Inspection Charges
2(a) Interest Under Section 7Q
2(b) Damages Under Section 14B
3 Miscellaneous payments
Total
Mode of payment:(Tick)
Cheque
Cash
DD
Transfer
Date of Deposit:
Name of the Establishment:
Cheque/DD No.
Address:
Cheque/DD date
PIN
Amount Recvd.(Rs.)
Name of the Depositor:
Deposit Bank Code:
Signature of Depositor:
Deposit Branch name:
Instructions to the employer
Bank Name (on which Cheque/DD drawn)
Use separate challan for each month.
Write legibly without any overwriting / correction / erasures.
Include Interest U/S 7Q for all belated remittances.
Pay the dues through local cheque only.
(To be filled in by the Bank)
Challan Reference No.
Date of Presentation:
Date Of Realisation
Date of Credit:M MY Y Y YM MY Y Y YD D