kb-3950

Annexure

Form ‘A’

[See Rule 3(4)]

Statement of employees’ and employers’ contribution for the six months ending on the 30th June and the 31st December, respectively

1. Name of the establishment
2. Name of the employer
3. Class of establishments (i.e. whether a factory of motor omni bus service, a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment). 4. Address of the establishment

5. Total number of employees whose names stands on the establishment register on the 30th June/the 31st December.
6. (a) Employees’ contribution at the rate of Rs. ______________

(b) Employers’ contribution at the rate of Rs. ______________ per employee,

7. Total of sub-entries (a) and (b) of entry 6.
8. Weather the contribution has already been paid to the Welfare Commissioner, if so, whether by cheque, money order or cash and details thereof.

Signature of the employer. Form ‘B’

[See Rule 3(5)]

Statement of employers’ contribution received by the Welfare Commissioner for six months ending on 30th June and 31st December respectively in the year ______________

Class of Establishment	Number of establishment	Amount of employers’ contribution received by the Welfare Commissioner
1	2	3
Rs. 1. Factories 2. Motor Omni bus Service 3. Shops 4.Commercial establishments 5. Residential hotel 6. Restaurants 7. Eating house 8. Theatres 9. Other place of public amusement or entertainment TOTAL

Signature of the

Welfare Commissioner

Form C

(See Rule 7)

I. Cash Book of the Office of the……..

Receipts

Date of receipt	Sl. No. of receipt	Details of the Receipts						P.O. Deposit
		Particulars of receipts	Receipt  No.	Bank deposit	Cash	Bank	Provisional receipts	Other deposits	R.B.F.
1	2	3	4	5	6	7	8	9	10
				Rs. P.	Rs. P.	Rs. P.	Rs. P.	Rs. P.
Opening Balance

Expenditure

Date of Expenditure	Sl. No.  subvoucher	Details of the payments						P.O. Deposit
		Particulars   of expenditure	Voucher No.	Bank deposit	Cash	Bank	Provisiona l receipts	Other deposits	R.B.
11	12	13	14	15	16	17	18	19	20
				Rs. P.	Rs. P.	Rs. P.	Rs. P.	Rs. P.

Total Receipts…………. Total Expenditure………. Grand Total………. Closing Balance……….   Grant Total……….

3. Classified Abstract of Pay and Allowance in Receipt of……. for the month of……20…..

Serial No.	Voucher No.	Date	Bill No.			Officers					Leave Salary Prov.
						Pay			Allow.		Pay		Allow.
1	2	3	4			5			6		7		8
Super visoryc um- Admin istrative S taff		Programme for Administrative Staff					Community necessities and educational staff					Total
Pay	Allow.	Pay		Allow.			Pay			Allo w.		Pay		Allow.
9	10	11		12			13			14		15		16
T.A. For staff		T.A. For members of the Board			Leave Travel Concession			Total of each  voucher			Initials
On tour	On transfer										Clerk		Supdt.
17	18	19			20			21			22		23

4. Classified Abstract of Contingent Expenditure of the…. Programme Expenditure

Serial No.	Voucher No.		Bill No.				Date				Place			Community Necessity
														Creche				Nursery			School
																		N.R.			R.
1	2		3				4				5			6				7			8
Tailoring		R.E.S.						Home				Subsidiary					Sewing				Reading
Classes		N.R.			R.			Industries				occupations for women					Machines				Rooms Centres
9		10			11			12				13					14				15
Libraries Centres		Workers Education				Entertainment and other
						Music and Socials etc.				National Special Days					Dramas  and Drama Festivals					Exhibition
16		17				18				19			20		21					22
R ecreation									Games and Sports
									Matches
Visual Instruction Cinema Show		Scouts  and Guides		Excursions and Tours					Conveyance and Refreshment							Entry Fees			First Aid			Prizes
23		24		25					26					27		28			29			30

Office/centre………….. for the Month of……..20……

Facilities of Conducting Programmes

Games materials	Repairs to play app. and playgrounds		N.	R.	Annual Sports and Misc.		Furniture		Electricity and lighting
									N.R.		R.
31	32		33		34		35		36		37
Rent Rates  and Taxes		Postage Exchange and		Printing and Stationery				Vehicles
		Bank Commission		N.R.		R.		N.R.		R.
38		39		40		41		42		43

		Serial No.	Voucher No.	Date	Bill No.
		1	2	3	4
Central Office……………………….
Divisional Office…………………..
Development Zone Office………
Circle Office………………………..
…………………………………………..
…………………………………………..
…………………………………………..
……………………………………………
Expenditure during the month of……………….
Add: Previous Progressive Expenditure upto…………
Adjustments	[Debit
	[Credit
Progressive expenditure upto……………………

And Allowances for the Month of……….20……….

Officer		Leave Salary Provision		Supervisory-cum- Administrative Staff				Programme for Administrative Staff
Pay	Allow	Pay	Allow	Pay		Allow		Pay		Allow
5	6	7	8	9		10		11		12
					Community necessities and educational staff				Total
					Pay		Allow		Pay		Allow
					13		14		15		16
Central office…………………………………. Divisional office……………………………… development Zone Office…………………. Circle Office…………………………………… ……………………………………………………… ……………………………………………………… ……………………………………………………… ………………………………………………………

Expenditure during the month of………….

Add: Previous Progressive Expenditure upto…………..

Adjustments [Debit

  [Credit

Progressive expenditure upto…………..

T.A. for staff		T.A. for members   of the Board	Leave Travel Concession	Total of each voucher	Initials
On tour	On transfer				Clerk	Supdt.
17	18	19	20	21	22	23

VI. Consolidated Abstract of Contingent Programme

Serial No.

Voucher No.

Bill No.

Date

Place

1

2

3

4

5

Expenditure during the month of……………….

Add: Previous Progressive Expenditure upto…………

Adjustments

[Debit

[Credit

Progressive expenditure upto……………………

Expenditure for the month of……………………

Expensiture

Community necessity

Tailoring  Classes

R.E.S.

Home Industries

Subsidiary  occupation for women

Creche

Nursery School

N.R.

R.

N.R.

R.

6

7

8

9

10

11

12

13

Sewing Machines

Reading Rooms at Centres

Libraries at Centres

Workers Education

14

15

16

17

Expenditure during the month of………….

Add: Previous Progressive Expenditure upto…………..

Adjustments [Debit

  [Credit

Progressive expenditure upto…………..

	Entertainment and other recreation
	Music and Socials etc.	National Special  Days		Dramas and Drama Festivals	Exhibition		Visual Instruction Cinema Show		Scouts  and Guides	Excursions and Tours
18	19	20		21	22		23		24	25
			Games and Sports
			Matches
			Conveyance and Refreshment			Entry Fees		First Aid			Prizes
26			27			28		29			30

Expenditure during the month of………….

Add: Previous Progressive Expenditure upto…………..

Adjustments [Debit

  [Credit

Progressive expenditure upto………….. Office/Centre………….

For the month of……………

Facilities for Conducting Programme

Games materials	Repairs to play app. and playgrounds		N.R.		Annual Sports and Misc.		Furniture		Electricity and lighting
									N.R.		R.
31	32		33		34		35		36		37
Rent Rates  and Taxes		Postage Exchange and Bank Commission		Printing and Stationery				Vehicles
				N.R.		R.		N.R.		R.
38		39		40		41		42		43

Expenditure during the month of………….

Add: Previous Progressive Expenditure upto…………..

Adjustments [Debit

  [Credit

Progressive expenditure upto…………..

Special item

Other Miscellaneous						Maintenance of Buildings and repairs
Replacement of Radio and Musical Instruments	Other  Miscellaneous	Home Nursing	Conveyance	Daily Wages
44	45	46	47	48	49	50

Expenditure during the month of………….

Add: Previous Progressive Expenditure upto…………..

Adjustments [Debit

  [Credit

Progressive expenditure upto…………..

Repairs		Administrative Contingency		Provident Fund Contribution	Gratuity Payment	Loans and Advances
51	52	53	54	55	56	57

Expenditure during the month of………….

Add: Previous Progressive Expenditure upto…………..

Adjustments [Debit

  [Credit

Progressive expenditure upto…………..

Investigation Claims	Legal fees	Grantin-aid			Total	Initials Clerk/Supdt.
58	59	60	61	62	63	64

Serial No.	Particulars of students			Year of deposit		D.	Receipts
	Name		Address			D.A.R.	Receipt No. and date		Amount
1	2		3	4		5	6		7
Initials		Withdrawals						Initials
		Voucher No.			Amount
8-11		8-11			8-11			8-11

9. Deposit Account for the Workers’ Club of Labour Welfare Centre at…………….. Dr.

Date	Voucher No.	Particulars	Reference No.	Amount	Initials

Cr.

Date	Particulars	Reference No.	DAR No.	Amount	Initials

10. Unpaid Accumulations Account Vide Section 3(1) of the Act for the Month of……….20….

Payments

Date	Particulars	Name of the persons	Payment made from amounts received during quarter	L.F.	V.No.	Amount

Receipts

Date	Particulars	Receipts No.	L.F.	Amount

11. Register of Quarterly Receipts of Unpaid Accumulations from the Name of Establishment………….

Account No. ………………

Period and particulars (Wage	Amount received
Period)	Referred of notice if  issued	Unpaid accumulations	Interest	Receipt No. and date
First Quarter ending 31st March, 20 Second Quarter ending 30th June, 20 Third Quarter ending 30th Sept., 20 Fourth Quarter ending 31st Dec., 20 Bonus for the year declared on
Total
First Quarter ending 31st March, 20 Second Quarter ending 30th June, 20 Third Quarter ending 30th Sept., 20 Fourth Quarter ending 31st Dec., 20 Bonus for the year declared on
Total
First Quarter ending 31st March, 20 Second Quarter ending 30th June, 20 Third Quarter ending 30th Sept., 20 Fourth Quarter ending 31st Dec., 20 Bonus for the year declared on
Total

Factory Establishment and Publication of Notices

File No. …………..

Address Factory

  Registered Office

1st Year

Section 6A

Name of the Establishment……………. Account No. …………………

File No…………… Address: Factory/Registered Office………………

Seria l No.	Name of the claimant	Refund Order  No. and date	Voucher No. and  date	Payment of unpaid accumulations from receipts
				As on	Quarter  ending	Quarter ending	Quarter ending	Quarter ending	Quarter ending
1	2	3	4	5	6	7	8	9	10

Amount received ………………

Date of first publication………….

Seria l No.	Name of the claimant	Payment of unpaid accumulations from receipts
		Quarter ending	Quarte r ending	Quarter ending	Quarter ending	Quarter ending	Quarter ending	Quarter ending	Remarks
1	2	11	12	13	14	15	16	17	18

Amount received ………………

Date of first publication………….

Form D

[See Rule 27(1)(a)]

Register of Wages

Name of the establishment……………. For the month of………………

Sl. No.	Name of employee		Ticket   and Badge No.			Occupation		Amount payable during the month
								Basic Wages		Over time	Dearness Allowance and other allowances			Bonus
1	2		3			4		5		6	7			8
Amount deducted during the month					Amounts actually paid during the month
Fines		Other deductions			Basic Wages		Over time		Dearness Allowance and other allowances				Bonus
9		10			11		12		13				14
Overtime Basic wages							Dearness allowances and other allowances					Bonus
15				16			17					18

Form E

[See Rule 27(1)(b)]

Register for Fines and Unpaid Accumulations for the Year, 20… Name of the Establishments……………..

		Quarter ending 31st March	Quarter ending 30th June	Quarter ending   30th September	Quarter ending 31st October
1.	Total realisation under fines
2.	Total amount becoming unpaid accumulations of
	(i) Basic wage
	(ii) Overtime
	(iii) Dearness Allowance and other allowances
	Total of (1), (2)