FORM NO-5-A (REVISED) (For unexempted Establishments only) The Employees' provident Fund Scheme, 1952 (Para 36-A) The Employees' Family Pension Scheme, 1971 (Para 16) The Employees' Deposit Linked Insurance Scheme, 1976 (Para-1) The Employees' Pension Scheme, 1995 RETURN OF OWNERSHIP TO BE SENT TO THE REGIONAL COMMISSIONER 1. Name of the establishment 2. Code No. of the establishment under the Employees' provident Funds and Miscellaneous Provisions Act, 195 2. 3. Postal Address of the establishment and its branches / departments if any 4. Industry or business in which engaged. 5. Date of First commencement of production / business (Trial/Regular) 6. Date of closure by the previous Management. 7. Whether run by the owner or leases (if by leases period of the lease should be indicated) 8. Particulars of owners. Name Father's Name *Status Age Date from Which in position Residential Address 1 2 3 4 5 6 1. 2. 3. 4. 5. *whether proprietor, Partner, MG, Partner, MG, Director etc. 9. If on Lease, Particulars of leases Name Father's Name Age Residential Address Date from Which in position 1 2 3 4 5 1. 2. 3. 4. 5. 10. If registered under the factories Act particulars of Manager/Occupier Name Father's Name Age Residential Address Date from Which in position 1 2 3 4 5 A. B. 11. Particular of The Persons mentioned above, who are in change of and responsible for the conduct of the business of the establishment. Name Father's Name Age Residential Address 1 2 3 4 1 2 3 4 5 Dated: Signature of the Employer/Designation seal of the Establishment Note: Any change in the information given above should be intimated in writing to the Regional Commissioner within fifteen days of such change by registered post and in the prescribed manner.
