Only for Un-Exempted Establishments FORM 12-A ( Revised) ( To be filled in by the EPFO )

Name and address of the Establishment EMPLOYEES' PROVIDENT FUNDS SCHEME, 1952 Establishment Status
EMPLOYEES' PENSION SCHEME [PARAGRAPH 20(4)]
Group Code
EMPLOYEES' DEPOSIT LINKED INSURANCE SCHEME, 76

Currency Period from 1st April, ____ to 31st March, ____

Statement of Contributions for the month of

Code No. Statutory rate of Contribution

Particulars Wages on which Amount of Contribution Amount of Contribution remitted Amount of Amount of Date of Remittance (Enclose Triplicate
Contributions are payable 3 4 Administrative Charges Administrative copies of Challan)
due Charges remitted
Recovered from the Payable by the Workers share Employer's share
workers employer
1 2 5 6 7

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

Total No. of Employees

(a) Contract Total No. of Employees Name & Address of the State Bank of India
(b) Rest Less : Excluded Employees bank in which the amount
(c) Total Total No. of Subscribers is remitted

Details of Subscribers E.P.F. Pension Fund E.D.L.I.

No. of subscribers as per last month

No. of new subscribers ( vide Form 5 )
No. of subscribers left service ( Vide Form 10)
(Net) Total number of subscribers Signature of the Employer with Official Seal