FORM No. 21 (See Rule 107) Annual Return under the Factories Act 1948 For this year ending on the 31st day of December, __________ 1. Registration No. of Factory 2. Name of Factory 3. Location of the Factory with Address 4. Postal Address of Factory 5. (a) Name of Occupier (b) Telephone Number, if any 6. (a) Name of Manager (b) Telephone Number, if any 7. (a) Nature of Industry (b) Nature of Major Manufacturing Process (Mention exactly manufactured) (c) Total Investment Made 8. Code Number 9. Whether the Factory is in (a) Public Sector or (b) Private Sector (c) Joint Sector or ive Sector (d) Co- Operative Sector (Strike out which is not applicable) Numbers of workers and particulars of Employment 10. Is the Factory seasonal? 11. No. of days worked in a year 12. (i) Total attendance (Man-days worked during the Year) (a) Men (b) Women (c) Children (ii) Number of workers attendance, days worked and wages paid 13. Average number of workers employed daily (See explanatory note) (a) Adults (b) Adolescents (c) Children (i) Men (ii) Male (iii) Male (i) Women (ii) Female (iii) Female 14. Total no. of Man-Hours worked including overtime Men Women Children 15. Average Number Hours worked per week Men Women Children 16. (a) Does the factory carry out any process or operation specified as hazardous under Section 2 (cb) and declared as dangerous under Section 87 of this Act? Month Number of Total Number of Total Amount Workers Attendance Days Worked of Wages Paid (b) If so, give the following information:- Name of the dangerous process or Average No. of persons employed Operations carried on daily in each of the processes or Operation given in Column 1 1 2 LEAVE WITH WAGES 17. Total number of workers employed during the year Men Women Children 18. Number of workers who were entitled to annual leave with wages during the year Men Women Children 19. Number of workers who were granted Leave during the year Men Women Children 20. (a) Number of workers who were discharged or dismissed from the service or quit employment or were superannuated of died, while in service during the year; (b) Number of such workers in respect of whom wages in lieu of leave were paid SAFETY OFFICE (Only for factories employing one thousand or more workers) 21. (a) Number of Safety Officers required to be appointed as per notification under Section 40-B of this Act (b) Number of Safety Officers appointed AMBULANCE ROOMS (Only for factories employing five hundred or more workers) 22. Is there an ambulance room provided in the factory as required under Section 45 of this Act read with Rule 102 schedule XI, paragraph 53. CANTEEN (Only for factories employing two hundred and fifty or more workers) 23. (a) Is there a canteen provided in the factory as required under Section 46 of this Act? (b) Is the canteen provided managed? (i) Departmentally, or (ii) Through a contractor? SHELTERS OR REST ROOMS AND LUNCH ROOMS (Only for factories employing one hundred and fifty or more workers) 24. (a) Are there adequate and suitable Shelters or Rest rooms provided in the factory? (b) Average daily number of children using cr che 25. (a) Number of Welfare Officers appointed (b) Have the names of welfare Officers been notified to the Chief Inspector of Factories, U.T. , Chandigarh? ACCIDENTS 26. (a) Total number of accidents (See explanatory note) (i) Fatal (ii) Non-Fatal (b) Accidents in which injured workers returned to work during the same year; (i) Numbers of accidents. (ii) Man- days lost due to accidents (c) Accidents (workers injured) occurring the year in which injured workers did not return to work during the year to which the return details: (i) Numbers of accidents. (ii) Man- days lost due to accidents (d) Attach Form no. 18 in case of those accidents, intimation of which has not been sent to the Chief Inspector of Factories at the time of the Accidents. Certified that the information furnished above is correct to the best of my knowledge and belief. Signature of the Manager Date FORM D Annual Return showing Payment of Maternity Benefit during the year ending on the 31st December. 1. Name of the Factory and full postal address _________________________________ 2. Name of Occupier _______________________________________________________ 3. Name of Manager ________________________________________________________ 4. Average number of women workers employed daily___________________________ 5. Number of women who claimed maternity benefit for actual births_______________ 6. Number of claims accepted and paid either fully or partially____________________ 7. Number of other persons who were paid maternity benefit _____________________ 8. Total amount of maternity paid ____________________________________________ (Including bonus paid) 9. Amount of Bonus included under column 8 __________________________________ 10. No. of claims accepted and paid either fully of partially_________________________ 11. No. of case in which women enjoyed full maternity leave prior to confinement_____ 12. Total amount of special bonus paid and no. of cases ___________________________ Dated Signature of Employees Annual Return under the Minimum Wages Act, 1948 for the year ending on 31st December, 20__________. 1. (a) Name of the employer/factory and postal address (b) Nature of Industry and Code No.__________________________________ 2. Average number of persons employed Adults ____________________________ Children___________________________ 3. No. of days worked during the year ___________________________________ 4. No. of man-days worked during the year (Total Attendances) Adults ____________________________ Children__________________________ 5. Total wages-Paid in cash________________________ Cash value of wages paid in kind____________________________________ 6. Total unclaimed amount including wages, bonus, fines/deductions etc. 7. Balance of fine fund at the beginning of the year________________________ 8. Deductions made on account of ______________________________________ Fine Damage or Loss Breach of Contract Total Number Amount Number Amount Number Amount Number Amount of cases of cases of cases of cases Rs. Rs. Rs. Rs. 9. Disbursement from funds:-Amount Rs. P. Page 22 of 151 Purposes(a)______________________ (b)______________________ (c)______________________ (d)______________________ 10. Balance of fine fund at the end of the year________________________ Signature of Employer/Officer/Manager. Date_____________________ Designation________________
