* Due Date for submission:- REG. FORM- 5

12^th May/ 11^th November*

Name of Branch Office __________________ Employer’s Code No. ______

RETURN OF CONTRIBUTIONS

EMPLOYEES’ STATE INSURANCE CORPORATON

(Regulation – 26)

Name & Address of the factory or establishment : ______________________________________

Particulars of the Principal employer(s)

a) Name : ______________________________________

b) Designation : ______________________________________

c) Residential Address : ______________________________________

Contribution Period from ______________________________ to _______________________________

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

Employees’ Share ____________________

Employer’s Share _____________________

Total Contribution _____________________

Details of Challans: -

Sl. No.	Month	Date of Challan	Amount	Name of the Bank and Branch
1.
2.
3.
4.
5.
6.

Total amount paid: Rs. _____________________

I declare that

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

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

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

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

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

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

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

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

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

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

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

1.

2.

3.

4.

5.

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

1.

2.

3.

4.

5.

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

Place _________________ Signature & Designation of the Employer

Date __________________ (with Rubber Stamp)

CERTIFICATE BY CHARTERED ACCOUNTANT

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

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

Signature & Seal

Of the Chartered Accountant with

Membership No

Important Instructions: Information to be given in “Remarks Column (No.9)”

i) If any I.P. is appointed for the first time and / or leaves during the contribution period indicate “A __________________ (date)” and/ or “L ____________________ (date)”.

ii) Please indicate Insurance Nos. in ascending order.

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

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

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

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

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

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

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

EMPLOYEES’ STATE INSURANCE CORPORATION

Employer’s Name and Address _____________________________________________

Employer’s Code No._____________________ Period from ___________ to ____________

Sl. No.	Insurance Number	Name of Insured Person	No. of days for which wages paid	Total amount of wages paid (Rs.)	Employee’s contribution deducted (Rs.)	Average Daily Wages (Rs.)	Whether still continues working	Remarks *
1.	2.	3.	4.	5.	6.	7.	8.	9.
		TOTAL

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

(FOR OFFICIAL USE)

1. Entitlement position marked.
2. Total of Col. 5 of Return checked and found correct/correct amount is indicated.	Countersigned
3. Checked the amount of Employer’s / Employee’s contribution paid which is in order/ observation memo. enclosed.

Countersignature ___________________

U.D.C. Head Clerk Branch Officer