FORM 5 RETURN OF CONTRIBUTIONS EMPLO YEES' ST A TE INSURANCE CORPORA TION (R egulation 26) Name of Branch Office ................................. Employer's Code No. ................... Name and A ddress of the factor y or establishment : .......................... P articulars of the P rincipal employer(s) (a) Name : .......................... (b) Designation : .......................... (c) Residential A ddress .......................... Contribution P eriod from ............................... to .......................... I fur nish below the details of the Employer's and Employee's share of contribu tion in respect of the under mentioned insured persons. I hereby declare that the retur n includes each and ever y employee, employed directly or through an immediate employer or in connection with the work of the factor y / establishment or any work............................... connected with the administration of the factor y / establishment or purchase of raw materials, sale or distribution of finished products etc. to whom the ESI A ct, 1948 applies, in the contribution period to which this retur n relates and that the contributions in respect of employer's and employee's share have been cor rectly paid in accordance with the provisions of the A ct and Regulations. Employees's Share ......................... Employer's Share .......................... T otal Contribution ........................ Details of Challans : - Sl.No. Month Date of Challan Amount Name of the Bank and Branch 1. 2. 3. 4. 5. 6. Place : ......................... T otal amount paid : Rs. ...................................... Date : ......................... Signature and Designation of the Employer (with R ubber Stamp) Important Instr uctions : Infor mation 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) F igures in Columns 4,5 & 6 shall be in respect of wage periods ended during the contribution period. (iv) Invariably strik e totals of Columns 4, 5 and 6 of the Retur n. (v) No over writing shall be made. Any cor rections, if made, should be signed by the employer . (vi) Ever y page of this Retur n should bear full signature and r ubber stamp of the employer . (vii) Daily wages in Column 7 of the retur n shall be calculated by dividing figures in Column 5 by figures in Column 4 to two decimal places. F or *CP ending 31st March, due date is 12th May F or CP ending 30th September , due date is 11th November . EMPLO YEE'S ST A TE INSURANCE CORPORA TION Employer's Name and A ddress ........................................................................................................................................ Employer's Code No. ...............................................P eriod from ......................................... to ...................................... Sl.No. Insurance Number Name of Insur ed P erson No. of days for which wages paid T otal amount of wages paid (Rs.) Employee's contribu- tion deducted (Rs.) A verage Daily W ages (Rs.) Whether still con- tinues working R emarks 1 2 3 4 5 6 7 8 9 T otal *Date of appointment and leaving the job may be given in remarks column. Signature of the Employer (FOR OFFICIAL USE) 1. Entitlement position mark ed. 2. T otal of Col. 5 of Retur n check ed and F ound cor rect/cor rect amount is indicated. 3. Check ed the amount of Employer's/Employee's contribution paid which is in order / obser vation memo enclosed. Countersignature ................................... U.D.C. Head Clerk Branch Officer
