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Form-5

The document is a Return of Contributions form submitted to the Employees' State Insurance Corporation for the period from October 2023 to March 2024 by SAI KRUPA DISTRIBUTORS PVT LTD. It details the employer's and employee's contributions, totaling 160.00, along with specific employee information and payment records. The form includes instructions for reporting changes in employee status and verification for official use.

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6 views

Form-5

The document is a Return of Contributions form submitted to the Employees' State Insurance Corporation for the period from October 2023 to March 2024 by SAI KRUPA DISTRIBUTORS PVT LTD. It details the employer's and employee's contributions, totaling 160.00, along with specific employee information and payment records. The form includes instructions for reporting changes in employee status and verification for official use.

Uploaded by

praveen.paws
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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FORM 5

RETURN OF CONTRIBUTIONS
EMPLOYEES' STATE INSURANCE CORPORATION

(Regulation 26)

Name of Branch Office : BO - Gulbarga Employer's Code No. 71000018100001099


Name and Address of the factory or establishment :SAI KRUPA DISTRIBUTORS PVT LTD - Plot No. 103, MSK Mill, Commercial Layout, Gulbarga, ,

Particulars of the Principal employer(s)


(a) Name :Sri Milind Shastri

(b) Designation :Partner

(c) Residential Address:# 42, Ghatge Layout, MSK Mill Road, Gulbarga-585103

Contribution Period from : Oct 2023 to Mar 2024

I furnish below the details of the Employer's and Employee's share of contribution in respect of the under mentioned insured persons. I hereby declare that the return

includes each and every employee, employed directly or through an immediate employer or in connection with the work of the factory / establishment or any

work...............................connected with the administration of the factory / establishment or purchase of raw materials, sale or distribution of finished products etc. to

whom the ESI Act, 1948 applies, in the contribution period to which this return relates and that the contributions in respect of employer's and employee's

share have been correctly paid in accordance with the provisions of the Act and Regulations.

Employees's Share 30.00


Employer's Share 130.00
Total Contribution 160.00

S.No. Month Challan Number Date of Challan Amount Name of the Bank and Branch
1 Oct-2023 07123141736571 11/11/2023 80.00 State Bank of India

2 Nov-2023 07123146180456 12/14/2023 80.00 State Bank of India

Place: Total amount paid: 160.00

Printed By: Page 1 of 2 Print Date: 17-Jan-2025 02:40:11 PM


Date: Signature and Designation of the Employer
(with Rubber Stamp)
Important Instructions : Information 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) Figures in Columns 4,5 & 6 shall be in respect of wage periods ended during
the contribution period.

(iv) Invariably strike totals of Columns 4, 5 and 6 of the Return.

For *CP ending 31st March, due date is 12th May


For CP ending 30th September, due date is 11th November

EMPLOYEES' STATE INSURANCE CORPORATION

Employer's Name and Address SAI KRUPA DISTRIBUTORS PVT LTD - Plot No. 103, MSK Mill, Commercial Layout, Gulbarga, ,

Employer's Code No period from Oct 2023 to Mar 2024

Sl.No. Insurance Name of Insured No. of days for Total amount of Employee's Average Whether
Remarks
Number Person which wages wages paid (Rs.) contribution Daily still continues
paid deducted Wages(Rs.) working

1 7117980572 MADHUSUDAN 20 4000.00 30.00 200.00 N


KORAVAR

*Date of appointment and leaving the job


Signature of the Employer
may be given in remarks column.

(FOR OFFICIAL USE)

1.Entitlement position marked.

2.Total of Col. 5 of Return checked and Found correct/correct amount is indicated

3.Checked the amount of Employer's/Employee's contribution paid which is in order / observation memo enclosed.

Countersignature____________________

U.D.C. Head Clerk Branch Officer

-- End of Report ---

Printed By: Page 2 of 2 Print Date: 17-Jan-2025 02:40:11 PM

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