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| Group Code

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| Statement of Contribution for the Month of..........................................

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| Statutory Rate of Contribution................

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Particulars

Wages on which contributions are payable

Amount of contribution

Amount of contributions remitted

Amount of administrative charges due

Amoutn of administrative charges remitted

Date of remittance

(enclose triplicate copies of challan)

Recovered from the workers

Payable by the employer

Worker's share

Employer's share

EPF A/c.No.01

Pension Fund A/c No.

10

NIL

NIL

NIL

NIL

DLI A/c No. 21

NIL

NIL

Total No. of Employee.....................................................

(a) Contract..............................

(b) Rest..................................

(c) Total.................................Name and address of the bank in which the amount is remitted.......................