From: Subject: * Due Date for submission:- Date: Fri, 5 Dec 2008 18:50:53 +0530 MIME-Version: 1.0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://esic.nic.in/Forms/FORM5.htm X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3350 * Due Date for = submission:-

   * Due Date for = submission:-              &nbs= p;            = ;       =20            &nbs= p;            = ;       =20            &nbs= p;   =20 REG.  FORM- 5

           =20 12th May/ 11th November*           &n= bsp;           &nb= sp;           &nbs= p;            = ;            =             &= nbsp;           &n= bsp;           &nb= sp;    =20

 

Name of=20 Branch Office _________________­­­_           &nbs= p;  =20            =20 Employer=92s Code No. ______

 

 

RETURN OF=20 CONTRIBUTIONS

 

EMPLOYEES=92 STATE = INSURANCE=20 CORPORATON

 (Regulation =96=20 26)

 

Name=20 & Address of the factory or establishment            =20 :           =20 ______________________________________

Particulars=20 of the Principal employer(s)

 

a)=20 Name               =20            =20            =20 :           =20 ______________________________________        =20

b) = Designation      =20            =20            =20 :           =20 ______________________________________

c) = Residential Address           =20            =20 :           =20 ______________________________________

 

Contribution=20 Period from ______________________________ to=20 _______________________________

 

           =20 I furnish below the details of the Employer=92s and Employee=92s = share of=20 contributions in respect of the under mentioned insured persons.  I hereby declare that the = return=20 includes each & every employee, employed directly or through an = immediate=20 employer or in connection with the work of the factory/ establishment or = any=20 work connected with the administration of the factory/ establishment or = purchase=20 of raw materials, sale or distribution of finished products etc. to whom = the ESI=20 Act, 1948 applies, in the contribution period to which this return = relates and=20 that the contributions in respect of employer=92s and employee=92s share = have been=20 correctly paid in accordance with the provisions of the Act and=20 Regulations.

 

Employees=92=20 Share ____________________

Employer=92s=20 Share _____________________

Total=20 Contribution _____________________

 

Details of=20 Challans: -

 

Sl.=20 No.

Month

Date=20 of Challan

Amount

Name=20 of the Bank and Branch

1.

 

 

 

 

2.

 

 

 

 

3.

 

 

 

 

4.

 

 

 

 

5.

 

 

 

 

6.

 

 

 

 

 

 

Total amount=20 paid: Rs. _____________________

 

 

 

I = declare=20 that

(a)   =20 All the=20 Records and Registers have been maintained as per provisions contained = in ESI=20 Act, Rules & Regulations framed therein.

(b)   =20 During the=20 period of return ________ No. of Declaration forms have been=20 submitted.

(c)   =20 During the=20 above period ________ No. of TICs have been = received.

(d)   =20 During the=20 above period _______ No. of PICs have been = received.

(e)   =20 During the=20 above period _____ No. of PICs have been distributed amongst the = eligible=20 IPs.

(f)     =20 During the=20 above period _______ accidents have been reported to the concerned = Branch=20 Office.

(g)   =20 During the=20 period _______ No. of employees directly employed by us have been = covered and a=20 total wages of Rs._________ have been paid to such=20 employees.

(h)   =20 During the=20 period _______ No. of employees directly employed by us have not been = covered=20 and a total wages of Rs._________ have been paid to such=20 employees.

(i)     =20 During the=20 period _______ No. of employees employed through immediate employer have = been=20 covered and a total wages of Rs._________ have been paid to such=20 employees.

(j)     =20 During the=20 period _______ No. of employees employed through immediate employer have = not=20 been covered and a total wages of Rs._________ have been paid to such=20 employees.

(k)   =20 Following=20 components of wages have been taken into consideration for the purpose = of=20 payment of contribution =96

1.

2.

3.

4.

5.

(j)      = Following=20 components of wages have not been taken into consideration for the = purpose of=20 payment of contribution =96

1.

2.

3.

4.

5.

The above=20 mentioned information is based on records and any information if found = incorrect=20 will render me liable for prosecutions under provisions of ESI Act and = action=20 for recovery of contribution due along-with interest and damages as per=20 provisions of the ESI Act.

 

 

 

Place=20 _________________           &n= bsp;           &nb= sp;           &nbs= p;            = ;     =20 Signature & Designation of the Employer

Date=20 __________________          =20            &n= bsp;           &nb= sp;           &nbs= p;            = ;          (with= =20 Rubber Stamp)

 

CERTIFICATE=20 BY CHARTERED ACCOUNTANT

(To be=20 submitted in case of employers employing 40 or more=20 employees)

 

           =20 Certified that I have verified the above return from the Records = &=20 Registers of M/s._____________________________________ and found it to = be=20 correct.

 

Signature=20 & Seal

Of = the=20 Chartered Accountant with

Membership=20 No

 

Important=20 Instructions: = Information=20 to be given in =93Remarks Column (No.9)=94

 

i)           = ;        =20 If = any I.P.=20 is appointed for the first time and / or leaves during the contribution = period=20 indicate =93A __________________ (date)=94 and/ or =93L = ____________________=20 (date)=94.

ii)           = ;       =20 Please=20 indicate Insurance Nos. in ascending order.

iii)           = ;     =20 Figures in=20 Column 4, 5 & 6 shall be in respect of wage periods ended during the = contribution period.

iv)           = ;      =20 Invariably=20 strike totals of Column 4, 5 & 6 of the = Return.

v)           = ;       =20 No = overwriting shall be made.  = Any=20 corrections, if made, should be signed by the = employer.

vi)           = ;      =20 Every page=20 of this Return should bear full signature and rubber stamp of the=20 employer.

vii)        = Daily=20 wages in Column 7 of the return shall be calculated by dividing figures = in=20 Column 5 by figures in Column 4 to two decimal = places.

 

For * CP=20 ending 31st March, due date is 12th=20 May

For   CP ending = 30th=20 September, due date is 11th November

 

EMPLOYEES=92 STATE INSURANCE = CORPORATION

 

Employer=92s=20 Name and Address=20 _____________________________________________

 

Employer=92s=20 Code No._____________________           &n= bsp;     =20 Period from ___________ to ____________

 

Sl.=20 No.

Insurance=20 Number

 

Name=20 of Insured Person

No.=20 of days for which wages paid

Total=20 amount of wages paid

(Rs.)

Employee=92s=20 contribution deducted

(Rs.)

Average=20 Daily Wages

(Rs.)

Whether=20 still continues working

Remarks=20 *

1.

2.

3.

4.

5.

6.

7.

8.

9.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL

 

 

 

 

 

 

 

 

*Date of=20 appointment and leaving the job may be given in remarks = column.           =20 Signature of the Employer

 

(FOR=20 OFFICIAL USE)

 

1.      =20 Entitlement=20 position marked.

 

2.      =20 Total=20 of Col. 5 of Return checked and found correct/correct amount is=20 indicated.

Countersigned

3.      =20 Checked=20 the amount of Employer=92s / Employee=92s contribution paid which = is in order/=20 observation memo. enclosed.

 

 

Countersignature=20 ___________________

 

 

U.D.C.           &nbs= p; =20            &nbs= p;           =20            =20 Head Clerk           &nbs= p;   =20            &nbs= p;           =20            =20 Branch Officer