FORM 'A'

(See Rule 3(5)) Statement of Employees' and Employers' contribution on 30th June and 31st December respectively. 1. Name of the Estibishment 2. Name of the employer 3. Class of establishment 4. Address of establishment 5. Total number of employees [as per section 2 (3)] whose names stand on the muster roll of the etablishmenton3OthJune/31st December. 6. Emplyers contribution @ 50 paise per employee. Rs. 7. Employers contribution @ 1 rupee per employee. Rs. 8. total of sub-entries (a) and (b) of entry 6. Rs. Signature of employer. (Table included: Class of establishments, No. of estabishments, Accout of Employers Contribution received by welfare Commissioner. Total Rs. Date. Signature of Welfare Commissioner)