THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952
[Paragraph 43]
and
THE EMPLOYEES’ PENSION SCHEME, 1995
[Paragraph 20(4)]

Statutory rate contribution:
Annual Statement of Contribution Currency period from 1st ________ 20 to ______ 20 No. of member voluntarily contributing at a higher rate:
Name & Address of the Establishment _______________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Code No. of the Establishment: GJ/ _________________________________________________________________________
Employees’ Contribution
Sr. No
Account No.
Name of the member in block letter
Wages retaining allowances (if any) and D.A. including cash value of food
Amount of workers contribution deducted from the wages E.P.F.
EPF difference between 10% & 81/3%
& 12% & 81/3%
Whichever is applicable as the case may be
Fund 81/3%
Refund of adovance
Rate of higher voluntary contribution (if any)
Remarks
concession paid during the currency period
1
2
3
4
5
6
7
8
9
10
Reconciliation of Remittance Total Rs. Rs. Rs. Rs.
Amount Remitted Adm. Charges Rs. Aggrigate Cols 5,6,7 Rs.
At 0.65% of wages Contribution ( )
No
Month
EPF Contribution including refund of Advances A/C No. 1 Rs.
Pension fund contribution A/C. No 10 Rs.
DLI Contribution A/C No. 21 Rs.
Adm. Charges A/C No. 21 Rs.
EDLI Adm. Charges 0.01% Rs.
Date of Remittance
1
March
2
April
3
May
4
June
5
July
6
Aug
7
Sept
8
Oct
9
Nov
10
Dec
11
Jan
12
Feb
Total
1.
Total number of contribution cards enclosed (Form 3A Revised)
2.
Certified that form 3A duly completed. Of all the members listed in this statement are enclosed, except those already sent during the course of the currency period for the final settlement of the
concerned member’s account vide ‘Remarks’ furnished against the names of the respective member above.
Signature of Employer (With office seal.)
Note:
(i)
The names of all members, including those who had left service during the currency period, should be include in this statement, Where the Form 3-A in respect of such member had left service were already sent to the Regional Office for the purpose of final settlement of their accounts, the fact should be stated against the members in the ‘Remarks’ column above thus 3-A already sent in the month of ________ 20 ___________
(ii)
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 adequate in the “Remarks” column
(iii)
In respect of those members who have not opted for Pension Fund their entire employers contributions @ 8 1/3% or 10% or 12% as the case may be shown under column No.6