FORM 12-A (Revised)
EMPLOYEES’ PROVIDENT FUND AND MISC. PROVIDENT ACT, 1952

Only for Un-Exempted Establishment Establishment Status
Name and Address of the Estt.
M/S, __________________ Group Code
___________________
___________________
Currency period from 1st April, 200 to 31st March, 200
Statement of contributions for the Month of
Code No. Statutory rate of contribution
G
J
%
Amount of Contribution
3
Amount of contribution remitted
4
Particulars
1
Wages on which Contributions are payable
2
Recovered from the workers
Payable by the employer
Worker’s share
Employer’s share
Amount of Administrative charge due
5
Amount of Administrative charges remitted
6
Date of Remittance
(enclose triplicate copies of Challan)
E.P.F. A/c No. 01
Pension Fund A/C No. 10
NIL
NIL
NIL
NIL
D.L.I. A/C No. 21
NIL
NIL
NIL
NIL
Total No. of Employees
a. Contract Name and address __________________
b. Rest of the bank in which __________________
the amount is remitted_________________
c. Total
Details of Subscribers
E.P.F.
Pension Fund
E.D.L.I.
No. of Subscribers as per last month
No. of New Subscribers (Vide From 5)
No. of New Subscribers left service (Vide Form 10)
(Nett.) Total Number of Subscribers
Signature of the Employer
with official Seal