EMPLOYEES' STATE INSURANCE CORPORATION EMPLOYEES' STATE INSURANCE CORPORATIONChallan Form for Deposit in A/C No. 1 Challan Form for Deposit in A/C No. 1

Date Month Year 0 Date Month Year

Employer's Code Bank & Branch Code Employer's Code 0 Bank & Branch Code

Name of Factory/Estt. & Address Name of Factory/Estt. & Address 000

Cheque/DD No. Dated Cheque/DD No. Dated

Drawn on (Name of the Bank). Period of Contribution Drawn on (Name of the Bank). Period of Contribution 0

Details of Payment Regular Contribution……. Interest ……… Damages …….. Others ……… Details of Payment Regular Contribution……. Interest ……… Damages …….. Others ………[Tick (p ) mode used] [Tick (p ) mode used]

No. of Employees Total Wages No. of Employees 0 Total Wages 0

Employees Contribution Employees Contribution 0Employer's Contribution Employer's Contribution 0#Interest #Interest#Damages #Damages#Others #Others

Total 0 Total 0

Total amount (in words) Total amount (in words) 0

#R.O. Demand Letter No. & Date #R.O. Demand Letter No. & Date

Signature Signature __________________________________________ __________________________________________ Name & Designation - Seal of Authorised Signatory Name & Designation - Seal of Authorised Signatory

(Acknowledgment) (Acknowledgment)(to be filled by Depositor) For use in Bank (to be filled by Depositor) For use in Bank

Received Rs. Bank Scroll No. ……………. Received Rs. Bank Scroll No. …………….(Rs. ______________________________________________ Only) Dated ……………………….. (Rs. ______________________________________________ Only) Dated ………………………..

In Cash/by Cheque/DD No. Dated Authorised Signature & Seal In Cash/by Cheque/DD No. Dated Authorised Signature & Seal

Mode of Payment [ Tick (p ) mode used] Cash …….. Cheque …*…. D.D. …….. Mode of Payment [ Tick (p ) mode used] Cash …….. Cheque …*…. D.D. ……..

(subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 of the Receiving Bank (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 of the Receiving Bank

EMPLOYEES' STATE INSURANCE CORPORATION EMPLOYEES' STATE INSURANCE CORPORATIONChallan Form for Deposit in A/C No. 1 Challan Form for Deposit in A/C No. 1

Date Month Year 0 Date Month Year

Employer's Code …………….. Bank & Branch Code Employer's Code …………….. Bank & Branch Code

Name of Factory/Estt. & Address Name of Factory/Estt. & Address 000

Cheque/DD No. Dated Cheque/DD No. Dated

Drawn on (Name of the Bank). Period of Contribution JANUARY 2009 Drawn on (Name of the Bank). Period of Contribution

Details of Payment Regular Contribution……. Interest ……… Damages …….. Others ……… Details of Payment Regular Contribution……. Interest ……… Damages …….. Others ………[Tick (p ) mode used] [Tick (p ) mode used]

No. of Employees Total Wages No. of Employees 0 Total Wages 0

Employees Contribution Employees Contribution 0Employer's Contribution Employer's Contribution 0#Interest #Interest#Damages #Damages#Others #Others

Total 0 Total 0

Total amount (in words) Total amount (in words)

#R.O. Demand Letter No. & Date #R.O. Demand Letter No. & Date

Signature Signature __________________________________________ __________________________________________ Name & Designation - Seal of Authorised Signatory Name & Designation - Seal of Authorised Signatory

(Acknowledgment) (Acknowledgment)(to be filled by Depositor) For use in Bank (to be filled by Depositor) For use in Bank

Received Rs. Bank Scroll No. ……………. Received Rs. Bank Scroll No. …………….(Rs. ______________________________________________ Only) Dated ……………………….. (Rs. ______________________________________________ Only) Dated ………………………..

In Cash/by Cheque/DD No. Dated Authorised Signature & Seal In Cash/by Cheque/DD No. Dated Authorised Signature & Seal(subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 of the Receiving Bank (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 of the Receiving Bank

Mode of Payment [ Tick (p ) mode used] Cash …….. Cheque …*…. D.D. …….. Mode of Payment [ Tick (p ) mode used] Cash …….. Cheque …*…. D.D. ……..