MESSAGE - PowerHR Forum€¦ · · 2016-06-022012-04-02 · MESSAGE It gives me immense pleasure to present you this compendium compiled by Power HR Forum containing various forms

MESSAGE

It gives me immense pleasure to present you this compendium compiled by Power HR Forum containing various statutory forms under important Industrial Laws. These forms cover the manner of applying for registration & licenece, maintaining various registers and records, filling of various returns.

This is the Volume –I covering the all the Forms under the Important Industrial Laws Central Rules plus the Delhi Factory Rules,1950 and Delhi Shops and Establishment Rules, 1954.

The unique part of this compendium is that it provides multiple indexes for easy searching and easy reference. Apart from indexes of Forms under each rules, consolidated indexes have been given separately for all registers and returns.

I am sure this will be of an important reference point for both HR and Line managers to facilitate the compliances under various labor enactments.

July 19, 2010 (R. P. Ojha) Executive Director (HR),POWERGRID &

Honorary Secretary– Power HR Forum

CONTENTS

1. Forms under

Industrial Laws Regulating Working Conditions 1.1. Industrial Employment (Standing orders) Central Rules,1946 Pg. A 1‐91.2. Building and other construction workers ( Regulation of employment and

condition of service ) Central Rules,1998

Pg. B 1‐33

1.3. Contract Labor (Regulation and Abolition) Central Rules,1971 Pg. C 1‐341.4. Inter‐state Migrant Workmen (Regulation of employment and condition of

Service) Central Rules,1980

Pg. D 1‐32

1.5. Mines Rules,1955 Pg. E 1‐311.6. Dangerous Machines (Regulation) Rules,2007 Pg. F 1‐51.7. Environment (Protection) Rules,1986 Pg. G 1‐81.8. Delhi Factory Rules,1950 Pg. H 1‐551.9. Delhi Shops and Establishment Rules,1954 Pg. I 1‐15

Industrial Laws Regulating Social Security 1.10. Employees Provident Funds Scheme,1952 Pg. J 1‐501.11. Employee’s State Insurance (Central) Rules,1950 Pg. K 1‐481.12. Workmen’s Compensation Rules, 1924 Pg. L 1‐22

Industrial Laws Regulating Wages 1.13. Minimum Wages (Central) Rules,1950 Pg. M 1‐161.14. Payment of Wages (Procedure) Rules, Pg. N 1‐91.15. Payment of Gratuity (Central) Rules,1972 Pg. O 1‐261.16. Payment of Bonus Rules,1975 Pg. P 1‐61.17. Equal Remuneration Rules, 1976 Pg. Q 1‐7

Industrial Laws Regulating Employment 1.18. Employment Exchange (Compulsory Notification of vacancies) Rules, 1960 Pg. R 1‐71.19. Apprenticeship Rules,1992 Pg. S 1‐17

Industrial Laws Regulating Employee Relations 1.20. Industrial Disputes (Central) Rules,1957 Pg. T 1‐351.21. Central Trade Union Regulations,1938 Pg. U 1‐10

2. Index of all forms for registration, certification & license Pg. V 1‐5

3. Index of all forms for maintaining registers & records Pg. W 1‐6

4. Index of all forms for filling returns Pg. X 1‐5

Forms under THE INDUSTRIAL EMPLOYMENT (STANDING ORDERS) CENTRAL RULES, 1946

C o m p i l e d b y P o w e r H R F o r u m P a g e A 1

Forms under

THE INDUSTRIAL EMPLOYMENT (STANDING ORDERS) CENTRAL RULES, 1946



INDEX FORM I Submission of Draft Standing orders

FORM II Certification of Standing Orders

FORM III Register under Section 8

FORM IV Memorandum of Appeal under Rule 7‐ A(1)

FORM IVA Notice of Change in Shift Working

FORM V Service Card



FORM I Submission of Draft Standing Orders

[Industrial Employment (Standing Orders) Act, 1946, section 3]

Dated..............20.... To The Certifying Officer Vide Notification No. L.R.11(98), dated 25th July ,1953

(Area) ………….. (Place) Sir, Under the provisions of section 3 of the Industrial Employment (Standing Orders) Act, 1946, I enclose five copies of the draft standing orders proposed by me for adoption in.......................................................................... ……………………………………………………

(Name) .......................................................................................................................................................................... (Place) (Postal address) an industrial establishment owned/controlled by me, with the request that these orders may be certified under the terms of the Act. I also enclose a statement giving the particulars prescribed in rule 5 of the Industrial Employment (Standing Orders) Central Rules, 1946.

I am etc.,

........................................... (Signature)

Employer/Manager



FORM II Certification of Standing Orders

[Notice under section 5 of the Industrial Employment (Standing Orders) Act, 1946]

Office of the Certifying Officer for ............................................................area/place...................................................

dated the......................20......... I................... Certifying Officer............., area, forward herewith a copy of the draft Standing Orders proposed by the employer for adoption in the................................ Industrial Establishment and submitted to me for certification under the Industrial Employment (Standing Orders) Act, 1946. Any objections which the workmen may desire to make to the draft Standing Orders should be submitted to me within fifteen days from the receipt of this notice.

...................................................

(Certifying Officer)

Seal

To

The Secretary,

Union.

Representative elected under rule 6 Name

Occupation

Industrial Establishment.



FORM III

Industrial Employment (Standing Orders) Act, 1946, Section 8

Register

PART I

INDUSTRIAL ESTABLISHMENT

S. No.

Date of the dispatch of the copy of standing orders authenticated under section 5 for the first time

Date of filing appeal

Date and nature of decision

Amendment made on appeal, if any

Date of the dispatch of the copy of the standing orders as settled on appeal

Any notice subsequently given or received of any amendment

Result

PART II

(Should contain the authenticated copy of the Standing Orders)



FORM IV

[See rule 7A (1) ] Memorandum of Appeal

[To be furnished in respect of each clause appealed against, separately]

1. Draft of the Standing Order under appeal as submitted by the employers. 2. Objection made/modification suggested, if any, to the Draft Standing Order under

appeal, by the Trade Union/ Representatives of workmen. 3. Standing Order under appeal, as certified by the Certifying Officer. 4. Grounds of appeal by the employers/ trade union/ workmen’s representatives.]



FORM IVA (See Standing Order 7A of Schedule I )

Notice of Change in Shift Working

Notice of discontinuance/ re‐starting of a shift working to be given by an employer

Name of employer.............................................................................................................

Address...............................................................................................................................

Dated the..................................................................... day of............................ 20..........

In accordance with Standing Order No..... of the Standing Orders certified and approved in respect of my/our industrial establishment, I/we hereby give notice to all concerned that it is my/our intention to discontinue/restart the shift working specified in the Annexure with effect from.......

Signature.............................

Designation.........................

Annexure

(Here specify the particulars of change in the shift working proposed to be effected).]

Copy forwarded to— 1. The Secretary of registred Trade Union, if any. 2. The Assistant Labour Commissioner (Central)/Labour Employment Officer (Here enter

office address of the Assistant Labour Commissioner (Central) Labour Employment Officer in the local area concerned).

3. The Regional Labour Commissioner (Central) Zone. 4. The Chief Labour Commissioner (Central), New Delhi.



FORM V (See Standing Order 1, Schedule I‐B)

Service Card

Name of Estt./Factory Ticket/Token No. 1. Register Serial No.

2. Name

3. Specimen Signature/Thumb Impression

4. Father’s or Husband’s name

5. Sex

6. Religion

7. Date of Birth

8. Place of Birth

9. Date of Joining

10. Details of Medical Certificate at the time of joining

11. Educational and other qualifications

12. Can Read

13. Can Write

14. Can Speak

15. Height

16. Identification Marks

17. Category of Workman

18. Department

19. Details of family members

20. Permanent Address

21. Local Address

22. Quarter No.

23. Life Insurance Policy No.

24. Provident Fund Account No.

25. Nominee for Gratuity

26. Nominee for Pension, if any



27. Employees’ State Insurance No.

28. Training courses attended (details)

29. (Eligibility for higher jobs)

30. Proficiency tests passed

31. Employment History Department Token No. Designation Scale of Pay Joined Left (Reason)

1 2 3 4 5 6

32. Absence Periods

From To Reason Medical reports regarding

suitability for continued employment

i. Sick Leave ii. Earned Leave iii. Any other leave

33. Maternity Benefit Workmen’s Compensation

Details of accidents:

34. Details of Disciplinary Action 35. Promotions

i. Details ii. Awards iii. Issue of Certificate of commendation

36. Date of superannuation 37. Any other matter.

Forms underBUILDING AND OTHER CONSTRUCTION WORKERS (REGULATION OF EMPLOYMENT AND CONDITIONS

OF SERVICE) CENTRAL RULES, 1998

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ B 1

Forms under

BUILDING AND OTHER CONSTRUCTION WORKERS

(REGULATION OF EMPLOYMENT AND CONDITIONS OF SERVICE) CENTRAL RULES, 1998




INDEX FORM I Application for Registration of Establishments Employing Building Workers

FORM II Certificate of Registration

Form III Register of Establishments

Form IV Notice of Commencement/Completion of Building or Other Construction Work

FORM V

Certificate of Initial and Periodical Test and Examination of Winches, Derricks and Their Accessory Gear

FORM VI

Certificate of Initial and Periodical Test and Examination of Cranes or Hoists and Their Accessory Gear

FORM VII Certificate of Initial and Periodical Test and Examination of Loose Gears

FORM VIII Certificate of Test and Examination of Wirerope Before Being Taken Into Use

FORM IX Certificate of Annealing af Loose Gears

FORM X Certificate of Annual Thorough Examination of Loose Gears Exempted From Annealing

FORM XI Certificate of Medical Examination

FORM XII Health Register

FORM XIII Notice of Poisoning or Occupational Notifiable Diseases

FORM XIV Report of Accidents and Dangerous Occurrences

FORM XV Register of Building Workers Employed by the Employer

FORM XVI Muster‐Roll

FORM XVII Register of Wages

FORM XVIII Form of Register Of Wages‐Cum‐Muster‐Roll

FORM XIX Register of Deductions For Damage Or Loss

FORM XX Register of Fines

FORM XXI Register of Advances

FORM XXII Register of Overtime

FORM XXIII Wage Book

FORM XXIV Service Certificate

FORM XXV Annual Return of Employer to be Sent to the Registering Officer

FORM XXVI

Register of Periodical Test—Examination of Lifting Appliance and Gears Etc




FORM I [See Rule 23(1)]

Application for Registration of Establishments Employing Building Workers

1. Name and location of the Establishment where building or other construction work is to‐be carried on.

2. Postal address of the Establishment.

3. Full name and permanent address of the Establishment, if any.

4. Full name and address of the Manager or person responsible for the supervision and control of the Establishment.

5. Nature of building or other construction work carried/is to be carried on in the Establishment.

6. Maximum number of building workers to be employed on any day.

7. Estimated date of commencement of building or the other construction work.

8. Estimated date of completion of the building or other construction work.

9. Particulars of demand draft, enclosed (name of the Bank amount, demand draft No. and date).

Declaration by the employer

i. I hereby declare that the particulars given above are true to the best of my knowledge and belief.

ii. I undertake to abide by the provisions of the Building and other Construction Workers (Regulation of Employment and Conditions of Service) Act, 1996 and the Rules made there under.

Principal Employer

Seal and Stamp

Office of the Registering Officer appointed under the Building and Other Construction Workers (Regulation of Employment and Conditions of Service) Act, 1996 and Central Rules made there under.

Date of Receipt of application:




FORM II [See Rule 24(1)]

No. Date

GOVERNMENT OF INDIA

Office of the Registering Officer

A Certificate of Registration is hereby granted under sub‐section (3) of Section 7 of the Building and Other Construction Workers (Regulation of Employment and Conditions of Service) Act, 1996 and the rules made thereunder, to M/s........................................................having the following particulars subject to conditions laid down in the Annexure :

1. Postal Address/location where building or other construction work is to be carried on by the Employer.

2. Name and address of employer including location of the building and other construction work.

3. Name and permanent address of the establishment.

4. Nature of work in which building workers are employed or are to be employed.

5. Maximum number of building workers to be employed on any day by the employer.

6. Probable date of commencement and completion of work,

7. Other particulars relevant to the employment of building workers.

Signature, of Registering Officer

with Seal

Annexure

The registration granted hereinabove is subject to the following conditions, namely—

a. the certificate of registration shall be non‐transferable;

b. the number of workmen employed or building workers in the establishment shall not, on any day, exceed the maximum number specified in the certificate of registration;

c. save as provided in these rules, the fees paid for the grant of registration certificate shall be non‐refundable;

d. the rates of wages payable to building workers by the employer shall not be less than the rates prescribed under the Minimum Wages Act, 1948 (II of 1948) for such employment where applicable, and where the rates have been fixed by agreement, settlement or award, not less than the rates so fixed; and

e. the employer shall comply with the provisions of the Act and the rules made thereunder.




FORM III [See Rule 25(2)]

Register of Establishments

SI. No.

Registration No. and date

Name and Address location of the establishment registered where a

building or other construction work is to be carried on

Name of the Employer and his address

Nature of building or other construction

work

(1) (2) (3) (4) (5)

Name and permanent address of

Establishment

Probable date of commencement

of work

Maximum No. of building workers to be employed on

any day

Probable duration of building or other

construction work & probable date of completion

Remarks

(6) (7) (8) (9) (10)




FORM IV [See Rules 26(3) and 239(1)]

Notice of Commencement/Completion of Building or Other Construction Work

1. i. Name and address (Permanent) of the establishment............................................................. ii. Name of the employer and address.........................................................................................

2. Name and situation of place where the building and other construction is proposed to be carried on.

3. No. and date of Certificate of registration..................................................................................... 4. Name and address of the person incharge of the construction work. 5. Address to which the communications relating to building or other construction work may be

sent. 6. Nature of work involved and the facilities including plant or machinery provided. 7. The arrangement storage of explosives, if any, to be used in building or other construction

work. 8. In case the notice is for commencement of work, the approximate duration of work. I/We hereby intimate that the building or other construction work (Name of work) having registration No. ..........................................dated...........................is likely to commence/is likely to be completed with effect from...............................................(date)/on (date).

Signature of the Employer To, The Inspector, …………………….. ……………………..




FORM V [See Rules 56 and 74(6), Schedule I]

Certificate of Initial and Periodical Test and Examination of Winches, Derricks and Their Accessory Gear

Test Certificate No............................................... (a) In case of construction site, name of the construction site where lifting‐ appliances are

fitted/installed/located:

Situation and Description of lifting appliances and Gear with distinguishing number or marks (if any), which have been tested, thoroughly examined

Angle to the horizontal of derrick boom at which test

load applied

Test load applied

Safe working load at the angle shown in column (2)

(1) (2) (3) (4) (Degrees) (Tonnes) (Tonnes)

Name and address of public service, association, company, or firm or testing

establishment making the test and examination

Name and position of the Competent Person of public service, association, company or firm

or testing establishment

I certify that on the...............................................................day of 19.............the lifting appliance shown in column (1) together with its necessary gear was tested in the manner set forth overleaf in my presence; that a careful examination of the said lifting appliances after the test showed that it had withstood the test load without injury or permanent deformation; and that the safe working load of the said lifting appliance and accessory gear is as shown in column (4). Signature of the Competent Person …………………… Date

Seal Registration/Authority number of the Competent Person




FORM VI [See Rules 56 and 74(b)]

Certificate of Initial and Periodical Test and Examination of Cranes or Hoists and Their Accessory Gear

Test Certificate No............................................... (a) Name of the construction site where cranes or hoists are fitted/installed/located: Situation & description

For jib cranes radius at the test load was applied

Test load applied

Safe working load for jib cranes at radius shown in column (2)

(1) (2) (3) (4) (Metres) (Tonnes) (Tonnes)

Name and address of public service, association firm or testing establishment

making the test and examination

Name and position of Competent Person of public service, association, company

or firm or testing establishment (5) (6)

I certify that on the.................................................................day of.............the above lifting appliances together with its accessory gear, was tested in the manner set forth overleaf; that a careful examination of the said lifting appliance and gear after the test showed that it had withstood the test load without injury or permanent deformation; and the safe working load of the said lifting appliance and gear is as shown in column (4).

Signature of the Competent Person *seal Date (See Note 3) Registration/Authority number of the Competent Person




FORM VII [See Rules 70 and 74(6)]

Certificate of Initial and Periodical Test and Examination of Loose Gears

(a) Name of the construction site where loose gears are fitted/installed/located : Distinguishing Number or

Mark

Description, dimension and material of gear/device

Number tested

Date of test

Test load applied (tonnes)

Safe working load (SWL) (tonnes)

(1)

(2)

(3)

(4)

(5)

(6)

Name and address of

manufacturer or suppliers

Initial test and examination certificate No. and date (only in case of periodical test and examination)

Name and address of public service association, company

or firm or testing establishment making the

test and examination

Name and position of Competent Person in

public service, association, company or firm or testing establishment

I certify that on the...........................................................day of......................... 19.......... the above gear was tested and examined in the manner set forth overleaf; that the examination showed the said gear/device withstood the test load without injury or deformation; and that the safe working load of the said gear/device is as shown in Column 6. Signature of the Competent Person *Seal Date Registration/Authority number of the Competent Person.



C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ B 1 0

FORM VIII [See Rules 62 and 74(b)]

Certificate of Test and Examination of Wirerope before Being Taken Into Use Test Certificate No...............................................

1. Name and address of maker or supplier:

2.

a) Circumference/diameter of rope

b) Number of strand

c) Number of wires per strand

d) Lay

e) Core

3. Quality of wire (e.g. Best Plough steel)

4.

a. Date of test of sample of rope

b. Load at which sample broke (tonnes)

c. Safe working load of rope (tonnes)

d. Intended use

5. Name and address of public service, association, company or firm or testing establishment making the test and examination.

6. Name and position of Competent Person in public service, association, company or firm or testing establishment making the test and examination.

I certify that the above particulars are correct, and that the test and examination were earned out by me and no defect effecting its safe working load (SWL) were found.

Signature of the Competent Person Seal Date

Registration/Authority number of the Competent Person.




FORM IX [See Rules 72 and 74(b)]

Certificate of Annealing of Loose Gears

Test Certificate No……………………… (a) Name of the Construction site where loose gears are fitted/installed/located: Distinguishing Number or

Mark

Description of gear

Number of the certificate of test & examination

Number annealed

Date of annealing

Defects found at careful

inspection after annealing

(1)

(2)

(3)

(4)

(5)

(6)

Name and address of public service association, company or firm or testing establishment carrying

out the annealing and inspection

Name and position of Competent Person of public service, association, company or

firm or testing establishment (7) (8)

I certify that on the date shown in column (5) the gear described in columns (1) to (4) was effectually annealed under my supervision that after being so annealed every article was carefully inspected; and that no defects affecting its safe working condition were found other than those indicated in column (6). Signature of the Competent Person Seal Date Registration/Authority number of the Competent Person.




FORM X (See Rules 69 and 73)

Certificate of Annual Thorough Examination of Loose Gears Exempted From Annealing (a) Name of the Construction site where loose gears are fitted/installed/located:

Distinguishing number or mark

Description of Gear Number of certificate of initial and

periodical test and examination

Remarks

(1) (2) (3) (4)

Name and address of public service, association,

company or firm or testing establishment making the test and examination

Name and position of Competent Person of public service, association, company or firm or

testing establishment

(5) (6)

I certify that on the..............................................day of.....................19.........the above gear, described in column (2) was thoroughly examined; and that no defects affecting its safe working condition were found other than those indicated in column (4).

Signature of the Competent Person Seal Date Registration/Authority number of the Competent Person.




FORM XI [See Rule 223(c)]

Certificate of Medical Examination 1. Certificate Serial No................................ Date................................................................ Date.............................................................. 2. Name............................................................... Indentification marks : (1).............................. (2)............................... 3. Fatherʹs Name.................................................... 4. Sex.................................................................. 5. Residence.........................................................son/daughter of.........................................................................:.......................................................................... .........................................................................:............................................................................. 6. Date of birth, if available...................................... and/or certificate age........................................... 7. Physical Fitness I hereby certify that I have personally examined (name) ........................................................... son/daughter/wife of.............................................residing at...........................................who is desirous of being employed in building and construction work and that his/her age as nearly as can be ascertained from my examination is ........................................................................... years and that he/she is fit for employment ..........................................................as an adult/adolescent. 8. Reason for—

1) refusal of certificate................................................................................................................. 2) certificate being revoked…………………………………………………………………………….

................................................................................................................................................. Signature/Left hand Thumb Signature with Seal impression of building worker Medical Inspector/C.M.O. Note.‐ 1. Exact details of cause of physical disability should be clearly stated. 2. Functional/productive abilities should also be stated if disability is stated.




FORM XII [See Rule 223(d)] Health Register

(In respect of persons employed in Building and other construction work involving hazardous processes)

Name of the Construction Medical Officer/Medical Inspector. (a) Mr......................... ..................... .From.............................................to.. ............................... (b) Mr.......... .................................... .From.... .................................. .....to.. ............................... (c) Mr.......... .................................... .From.... .................................. .....to.. ............................... SI. No.

Works No.

Name of building worker

Sex Age (Last birthday)

Date of employment of present work

Date of leaving or transfer to other work

(1) (2) (3) (4) (5) (6) (7) 1. 2. 3. 4. 5. Reason for leaving

transfer or discharge

Nature of job or occupation

Raw Material or by product

handled

Date of medical examination by

certifying Surgeon Medical

Inspector/CMO

Results of medical

examination

If suspended from work,

state period of suspension with detailed

reasons

(8) (9) (10) (11) (12) (13) 1. 2. 3. 4. 5. Certified fit to resume duty on with signature

of Medical Inspector/C.M.O. (14)

If certificate of unfitness or suspension issued to worker

(15) 1. 2. 3.

Signature with date of Medical Inspector/CMO Note.‐ (i) column (8)—Detailed summary of reason for transfer or discharge should be stated, (ii) column (12) should be pressed as fit/unfit/suspended.




FORM XIII [See Rule 230(a)]

Notice of Poisoning or Occupational Notifiable Diseases

1. Name and address of the employer : 2. Name of the building worker and his work No., if any : 3. Address of the building worker : 4. Sex and Age : 5. Occupation : 6. State exactly what the patient was doing at the time of contracting the disease 7. Nature of poisoning or disease from

which the building worker is suffering from : Date : Signature of the employer/CMO Note.‐ When a building worker contracts any disease specified in Schedule XII, a notice in this form

shall be sent forthwith to the Director General.




FORM XIV [See Rule 210(7)]

Report of Accidents and Dangerous Occurrences

1. Name of the project/work

2. Location of project/work

3. Stage of construction work

4. Particulars of Employer (a) Main contractor firm/Co. : (b) Sub‐contractorʹs particulars :

Name Name: Address Address: Phone Nos. Phone Nos. Nature of Business Nature of Business

5. Particulars of injured person

a) Name (First) (Middle) (Surname)

b) Home Address c) Occupation d) Status of the worker :

Casual Permanent

e) Sex : Male Female f) Age g) Experience Marital status: Married/Unmarried/Divorced

6. Particulars of Accident

a) Exact place where accident occurred b) Date c) Time d) What the injured person was doing at the time of accident? e) Weather condition f) How long employed by you for this particular job? g) Particulars of equipment/machine/tool involved & condition of the same after the accident

occurred h) Brief description of the accident

7. Nature of injuries a) Fatal




b) Non fatal c) If non‐fatal, state precisely the nature of injuries (Describe in detail the nature of

injury, for instance fracture of right arm, sprain etc.) d) First‐Aid : Given : Not given : e) If not, give the reasons f) Name & designation of the person by whom

first‐aid was given g) If admitted to hospital,

Name of the hospital: Address of the hospital Phone No. Name of Doctor 8. Mode of transport used Ambulance Truck Tempo Taxi Private Car 9. How much time was taken to shift the injured person?

a. If very late, state the reasons b. How the reporting was made?

Telephone Telegram Special Messenger Letter c. Who visited the accident site first and what action was proposed by him? d. What are the actions taken for the investigation of the accident by the

employer? (Describe about photographs/ Video film/measurements taken etc.) 10. Particulars of the persons given witness: (a) Name Address Occupation 1. 2. 3. 4. (b) Whether Temporary Permanent 11. Particulars in case of fatal: Date Whether registered with Building and other Construction Workersʹ Welfare Board If yes give Reg No. 12. Dangerous Occurrences as covered under the Regulation No. (Give details)

a) collapse or failure of lifting appliances, b) hoist conveyors etc.




c) collapse or subsidence of soil, any wall, d) floor, gallery etc. e) collapse of transmission towers, pipeline, f) bridges etc. g) explosion of receiver, vessel etc. h) fire and explosion i) spillage or leakage of hazardous substances j) collapse, capsizing, toppling or collision of transport equipment. k) leakage or release of harmful toxic gases at the l) construction site. m) failure of lifting appliance, loose gear, hoist n) or building and other construction work machinery, o) transport equipment etc.

13. Certificate from the Employer or authorized signatory. I certify that to the best of my knowledge and belief, the above particulars are cofrect in every respect. Place: Signature Date: Designation c.c forwarded for information and follow‐up action : 1. 2. 3. Note.‐ If more than one person is involved, then for each person, information is to be filled up in separate forms.




FORM XV (See Rule 240)

Register of Building Workers Employed by the Employer Name and address Name and permanent of establishment address of establishment were building and other construction work is to be carried on nature and location of work……………………………

SI. No.

Name and Surname of workman

Age and Sex

Fatherʹs/Husbandʹs name

Nature of Employment/ Designation

Permanent Home address of workman (Village and Taluk and

Distt.)

(1) (2) (3) (4) (5) (6) 1. 2. 3. 4.

Local Address

Date of commencement of

employment

Signature or thumb impression of workman

Date of termination of employment

Reasons for termination

(7)

(8)

(9)

(10)

(11)

1. 2. 3. 4. If the building worker is/was beneficiary, the date of registration as a beneficiary, the registration No. and the name of

Welfare Board

Remarks

1. 2. 3. 4.




FORM XVI [See Rule 241(1 )(a)] Muster‐Roll

Name and permanent address Name and address of establishment where of the establishment building or other construction work is earned

on/is to be carried on Name and address of Employer

Nature of building or other construction work Name and address of Employer For the month of ……………… SI. No.

Name of the building worker

Fatherʹ s/Husbandʹ s

name

Sex

Dates Remarks

(1) (2) (3) (4) (5) (6) 1. 2. 3. 4. 5.

1.

2.

3.

4.

5.




FORM XVII [See Rule 241 (1)(a)] Register of Wages

Name and address of the Name and address of the Establishment Establishment where building or other construction work is ……………………………………….. carried on Nature of building Name and address of the Employer or other construction work ……………………………………….. Wage period: Monthly ……………………………… SI. No.

Name of workman

Serial No. in the register of workman

Designation/nature of work done

No. of days worked

Units of work done

(1) (2) (3) (4) (5) (6)

Daily rate of wages/piece

rate

Amount of wages earned

Basic wages

Dearness allowances

Overtime

Other cash payments (Nature of payment to be

indicated)

Total

(7) (8) (9) (10) (11) (12)

Deductions, if any, (indicate nature)

Net amount paid

Signature/Thumb impression of workman

Initial of employer or his representative

(13)

(14)

(15)

(16)




FORM XVIII [See Rule 241(1 )(a)]

Form of Register of Wages‐Cum‐Muster‐Roll Name and address of the establishment Name and permanent where building or other construction address of establishment work is carried on/is to be carried on Nature of building or other construction work SI. No. SI. No. in

Register of building workers

Name of employee

Designation/ nature of work

Daily attendance/

units worked

Total attendance/ units of work

done (1) (2) (3) (4) (5) (6)

1. 2. 3. 4. 5.

1. 2. 3. 4. 5.

Daily rate of

wages/piece rate Amount of wages earned

Basic wages Dearness allowances

Overtime Other cash payments (nature of payment to be indicated)

Total

(7) (8) (9) (10) (11) (12)

Deduction if any, (indicate nature)

Net amount paid

Signature/Thumb impression of workman

Initial of employer or his representative

(13) (14) (15) (16)




FORM XIX [See Rule 241(1) (b)]

Register of Deductions for Damage or Loss Name and Address of establishment where building or other construction work is carried on/is to be carried on

Name and permanent address of building workers

Name and permanent address of employer

Nature of building or other construction work SI. No.

Name of work

Fatherʹs/ Husbandʹs Name

Designation/nature of

employment

Particulars of damage or loss

Date of damage or

loss

Whether building

worker showed cause against deduction

(1) (2) (3) (4) (5) (6) (7)

Name of person in whose presence building workerʹs

explanation was heard

Amount of deduction imposed

No. of installments

Date of recovery First installment

Last installment

(8) (9) (10) (11) (12)




FORM XX [See Rule 241(1 )(b)] Register of Fines

Name and address of establishment Name and permanent address of where building or other construction establishment work is carried on/is to be carried on Nature of building and other construction work Name and address of employer SI. No.

Name of the building worker


Designation/nature of employment

Act/omission for which fine imposed

Date of offence

(1) (2) (3) (4) (5) (6)

Whether building worker

showed cause against fine

Name of person in whose presence building workerʹsexplanation was

heard

Wage periods and wages payable

Amount of the fine imposed

Date on which fine realized

Remarks

(7) (8) (9) (10) (11) (12)




FORM XXI [See Rule 241(!)(b)]

Register of Advances Name and address of establishment where building or other construction work is carried on/is to be carried on

Name and permanent address of establishment

Nature of building or other construction work

Name and address of the employer

SI. No. Name Fatherʹs/Husbandʹs

name Nature of

employment/ Designation

Wage period and wages payable

Date and amount of

advance given (1) (2) (3) (4) (5) (6)

Purpose(s) for

which advance given

No. of installments by which advance

to be repaid

Date and amount of each installment

repaid

Date on which last installment was

repaid

Remarks

(7)

(8)

(9)

(10)

(11)




FORM XXII [SeeRule241(l)(c)]

Register of Overtime Name and address of Establishment where building or other construction work is carried on/is to be carried on

Name and permanent address of establishment

SI. No. Name of

the building worker


Sex

Designation/Nature of employment

Date on which overtime worked

(1) (2) (3) (4) (5) (6)

Total overtime worked or

production in case of piece rated

Normal rates of wages

Overtime rates of wages

Overtime earnings

Date on which overtime wages

paid

Remarks

(7) (8) (9) (10) (11) (12)




FORM XXIII [SeeRule241(2)(a)] Wage Book

Name and Address of Employer Name and address of the establishment where building or other construction work is carried on

Name and permanent address of establishment Nature of building or other construction work

For the Week/ Fortnight/ Month ending.............

1. No. of days worked..... ..................................................

2. No. of units worked in case of piece‐rate workers................................

3. Rate of daily/monthly wages/piece‐rate................................................

4. Amount of overtime wages..................................................................

5. Gross wages payable.............................................................................

6. Deductions, if any, on account of the following :

a) fines.

b) damage or loss.

c) loans and advances.

d) subscription towards provident fund.

e) subscription towards the Building Workersʹ Welfare Fund.

f) any other deductions e.g. subscriptions to Cooperative Society or account of loans from Cooperative Society/housing loan, or contribution to any relief fund as per provision of clause (P) of sub‐section (2) of Section 7 of the Payment of Wages Act or for payment of any premium of Life Insurance Corporation.

7. Net amount of wages paid.......................................................................

Initials of the employer

or his Representative




FORM XXIV [See Rule 241 (2) (b)] Service Certificate

Name and permanent address of the establishment

Name and address/location where the building or other construction work carried on/to be carried on

Nature and location of work : .......................................................................

Name and address of the workman : .......................................................................

Age or Date of Birth : ....................................................................... Identification Marks : .......................................................................

Fatherʹs/Husbandʹs name : ....................................................................... SI. No.

Total period for which employed

From To

Nature of work done

Rate of wages with particulars of unit in case of (piece work)

If the building worker was a beneficiary his

registration No., date and the name of Board

(1) (2) (3) (4) (5) (6)

Reasons/grounds on which the employment terminated Remarks

(7) (8)

Signature




FORM XXV (See Rule 242)

Annual Return of Employer to be Sent to the Registering Officer

Year ending 31st December..................................... 1. Full name and full address of the establishment of the building and other construction work (Place,

Post Office, District) 2. Name and permanent address of the establishment 3. Name and address of the employer 4. Nature of building and other construction work carried on 5. Full name of the Manager or person responsible for supervision and control of the establishment 6. Number of building workers ordinarily employed 7. Total number of days during the year on which building workers were employed 8. Total number of man‐days worked by building workers during the year 9. Maximum number of building workers employed on any day during the year 10. The number of accident that took place during the year as under:

a. The total number of accidents.

b. The number of accidents resulting in disablement of building workers for less than 48 hours, the number of building workers involved and the number of man‐days lost.

c. The number of accidents resulting in disablement of building workers beyond 48 hours but not resulting in any permanent partial or permanent total disablement, the number of building workers involved, and the number of man‐days lost on account of such accidents.

d. The number of accidents resulting in permanent partial or total disablement, the number of building workers involved and the number of man‐days lost on account of such accidents.

e. The number of accidents resulting in deaths of building workers and the number of resultant deaths.

The Chief Inspector or Inspectors appointed by a State Government under the Act shall direct the owners of establishments registered under this Act, to send the copies of Annual Returns submitted by the employers of registered establishments in respect of the concerned State Government or appropriate Government to the Director General of Inspections by virtue of provisions of Section 60 of the Act.

The Chief Inspector or Inspectors appointed under this Act by a State Government shall direct the owners of such establishments as are registered under this Act by registering officers appointed by the concerned State Government to send copies of the Annual returns to the Director General by virtue of provisions of Section 60 of the Act.

11. Change, if any, in the management of the establishment, its location, or any other particulars furnished to the Registering Officer in the application for Registration indicating also the dates.

Employer

Place …………..

Date…………….




FORM XXVI [See Rule 74(fo)]

Register of Periodical Test—Examination of Lifting Appliance and Gears Etc.

PART‐ I Initial and periodical load test of lifting appliances and

their annual thorough examination ʺThorough examinationʺ means a visual examination, supplemented, if necessary, by other means such as a hammer test, carried out as carefully as the conditions permit, in order to arrive at a reliable conclusion as to the safety of the parts examined, and if necessary, for such examination parts of the lifting appliances and gear shall be dismantled.

(A)

Initial and periodical load tests of lifting appliance

Situation and description of

lifting appliances tested with

distinguishing number of marks if

any

No. of certificate of test and

examination of competent person

I certify that on the date on which I have appended by signature the

lifting appliance shown in column ( 1 ) was tested and no defects affecting its safe working condition were found other than those shown in column (5)

Remarks (to be signed and dated)

Date and signature with seal

Date and signature with

seal

(1) (2) (3) (4) (5)

(B)

Annual thorough examination

I certify that on the date to which I have appended my signature, the lifting appliance shown in column (1) was thoroughly examined and no defects affecting its safe working conditions were found other than those shown in column (12)

Remarks to be signed and dated







(6) (7) (8) (9) (10) (11) (12)

1. 2.

Note.— If all the lifting appliances are thoroughly examined on the same date it will be sufficient to enter in column (1) ʺAll lifting appliancesʺ. If not, the parts which have been thoroughly examined on the dates must be clearly indicated.




PART II

Initial and periodical load test of loose gears and annual thorough examination

List of loose gear:

The following classes of loose gears namely—

1. Chains made of malleable cast iron;

2. Plate link chains;

3. Chains, rings, hooks, shackles and swivels made of steel;

4. Pitched chains;

5. Rings, hooks, shackles and swivels permanently attached to pitched chains, pulley blocks, container, spreaders, trays, slings, baskets, etc. and any other similar gear.

6. Hooks and swivels having screw‐threaded parts or ball bearings or other case‐heardened parts; and

7. Bordeaux connections.

Distinguishing No. or marks

Description of loose gear tested and

examined

No. of certificates of test and examination of

competent person

I certify that on the date to which I have

appended my signature the loose gears shown in

column (1) and (2) were tested and no defects affecting the

safe working condition were found

other than those shown in column (6)



(1) (2) (3) (4) (5)

1.

2.

3.

4.

5.




Annual thorough examination of loose gears


I certify that on the date to which I have appended my signature the loose gears shown in columns (1) and (2) were thoroughly examined and no defects affecting their safe working conditions were found‐other than those shown in column (10)


seal


seal


seal


(6) (7) (8) (9) (10)

1.

2.

3.

4.

5.

PART III

Annealing of Chains, Rings, Hooks, Shackles and Swivels (other than those exempted)

(See PART II)

12.5 mm and smaller chains, rings, hooks, shackles and swivels in general use.

If used with lifting appliance driven by power, must be annealed once at least in every six months. If used solely with lifting appliance worked by hand, must be annealed once at least in every twelve months.

Other chains, rings, hooks, shackles and swivels in general use.

If used with lifting appliance driven by power, must be annealed once at least in twelve months.

If used solely with lifting appliance worked by hand, must be annealed once at least in every two years.

Note.‐It is recommended though not required by rules that annealing should be carried out in a suitably constructed furnace heated to temperature between 1100 degree and 1300 degree Fahrenheit or 600 degree and 700 degree centigrade, for a period between 30 and 60 minutes.




Distinguishing No. or

mark

Description of gear annealed

No. of the certificate of test and

examination

I certify that on the date to which I have appended my

signature, the gear described in Cols. 1 & 2 was effectually

annealed under my supervision; that after being so annealed every article was carefully

inspected and that no defects affecting its safe working

condition were found other than those shown in Col. 7

Remarks (to be signed and

dated)




(1) (2) (3) (4) (5) (6) (7)

Forms underCONTRACT LABOR (REGULATION AND ABOLITION) CENTRAL RULES, 1971

C o m p i l e d b y P o w e r H R F o r u m P a g e - C 1

Forms under

CONTRACT LABOR (REGULATION AND ABOLITION) CENTRAL RULES, 1971



INDEX FORM I Application for Registration of Establishments Employing Contract Labour


FORM III Register of Establishments

FORM IV Application for Licence

FORM V Form of Certificate by Principal Employer

FORM V‐A Application for Adjustment of Security Deposit

FORM VI License

FORM VI‐A Notice of Commencement/Completion of Contract Work

FORM VI‐B Notice of Commencement/Completion of Contract Work

FORM VII Application for Renewal of License

FORM VIII Application for Temporary Registration of Establishment Employing Contract Labour

FORM IX Temporary Certificate of Registration

FORM X Application for Temporary License

FORM XI License for a Period of not More Than Fifteen Days

FORM XII Register of Contractors

FORM XIII Register of Workmen Employed by Contractor

FORM XIV Employment Card

FORM XV Service Certificate

FORM XVI Muster Roll


FORM XVIII Form of Register of Wages‐cum‐Muster Roll

FORM XIX Wage Slip

FORM XX Register of Deductions for Damage or Loss

FORM XXI Register of Fines

FORM XXII Register of Advances

FORM XXIII Register of Overtime

FORM XXIV Return to be Sent by the Contractor to the Licensing Officer

FORM XXV Annual Return of Principal Employer to be Sent to the Registering Officer



FORM I [See Rule 17(1)]

Application for Registration of Establishments Employing Contract Labour

1. Name and location of the Establishment. 2. Postal address of the Establishment. 3. Full name and address of the Principal Employer (furnish fatherʹs name in the

case of individuals). 4. Full name and address of the Manager or person responsible for the supervision

and control of the establishment. 5. Nature of work carried on in the Establishment. 6. Particulars of contractors and Contract Labour:

a. Names and Addresses of Contractors. b. Nature of work in which contract labour is employed or is to be employed. c. Maximum number of contract labour to be employed on any day through

each contractor. (cc)Estimated date of commencement of each contract work under each contractor.]

d. Estimated date of termination of employment of contract labour under each Contractor.

7. Particulars of demand draft enclosed (Name of the Union Bank, amount, demand draft No. and date).]

I hereby declare that the particulars given above are true to the best of my knowledge and belief.

Principal Employer

Seal and Stamp

Office of the Registering Officer.

Date of receipt of application.




Certificate of Registration

Government of India No. Date………………….

Officer of the Registering Officer

A Certificate of Registration containing the following particulars is hereby granted under sub‐section (2) of Section 7 of the Contract Labour (Regulation and Abolition) Act, 1970, and the rules made thereunder, to ................................................................................... ……………………………………………………………………………………………………………………………………………………………………………………………………………… 1. Nature of work carried on in the Establishment. 2. Names and addresses of Contractors. 3. Nature of work in which Contract Labour is employed or is to be employed. 4. Maximum number of Contract Labour to be employed on any day through each

Contractor. 5. Other particulars relevant to the employment of Contract Labour.

Signature of Registering Officer with Seal.



FORM III [See Rule 18(3)]


SI. No. Registration No. and date

Name and address of theestablishmentregistered

Name of thePrincipal Employer

and his address

Type of business, trade,

industry, manufacture or occupation,

which is carried on in the

establishment

Total No. of workmen directly employed

1 2 3 4 5 6

Particulars of Contractor and Contract Labour Name and address of contractor

Nature of work in which

Contract Labour is employed or is to be employed

Maximum No. of Contract Labour to be employed on

any day

Probable duration of employment of contract labour

Remarks

7 8 9 10 11



FORM IV [See Rule 21(1)]

Application for License

1. Name and address of the contractor (including his fatherʹs name in case of individuals). 2. Date of birth and age (in case of individuals). 3. Particulars of Establishment where Contract Labour is to be employed—

(a) Name and address of the Establishment. (b) Type of business, trade, industry, manufacture or occupation, which is carried on in the

Establishment. (c) Number and date of Certificate of Registration of the Establishment under the Act. (d) Name and address of the Principal Employer.

4. Particulars of Contract Labour— 1) Nature of work in which Contract Labour is employed or is to be employed in the

Establishment. 2) Duration of the proposed contract work (give particulars of proposed date of commenc‐

ing and ending). 3) Name and address of the Agent or Manager of Contractor at the worksite. 4) Maximum number of Contract Labour proposed to be employed in the Establishment on

any date. 5. Whether the contractor was convicted of any offence within the preceding five years. If so,

give details. 6. Whether there was any order against the contractor revoking or suspending licence or

forfeiting security deposits in respect of an earlier contract. If so, the date of such order. 7. Whether the contractor has worked in any other establishment within the past five years. If so,

give details of the Principal Employer, Establishments, and nature of work. 8. Whether a certificate by the Principal Employer in Form V is enclosed. 9. Amount of licence fee—name of the Union Bank, demand draft No. and date.] 10. Amount of security deposit—name of the Union Bank, demand draft No. and date. Note.— The application shall be accompanied by demand draft and the challan for the

appropriate amount and a certificate in Form V from the principal employer ……………………. date of the receipt of the application with ʹdemand draftʹ and the challan for fees/security deposit.]

Declaration.— I hereby declare that the details given above are correct to the best of my knowledge and belief.

Signature of the Applicant (Contractor)

Place .............. Date ............... Note.—The application should be accompanied by a Treasury Receipt for the appropriate amount

and a certificate in Form V from the Principal Employer.

(To be filled in the office of the Licensing Officer) Date of receipt of the application with challan for fees/security deposit.

Signature of the Licensing Officer.



FORM V [See Rule 21(2)]

Form of Certificate by Principal Employer Certified that I have engaged the applicant (name of the contractor) as a contractor in my establishment. I undertake to be bound by all the provisions of the Contract Labour (Regulation and Abolition) Act, 1970, and the Contract Labour (Regulation and Abolition) Central Rules, 1971, insofar as the provisions are applicable to me in respect of the employment of Contract Labour by the applicant in my establishment. Place ................... Signature of Principal Employer Date .................... Name and address Establishment



FORM V‐A [See Rule 24(1‐A)]

Application for Adjustment of Security Deposit

Name and address of the Contractor

No. and date of licence

Date of expiry of previous licence

Whether the licence of the contractor was suspended or

revoked

(1) (2) (3) (4)

No. and date of the demand draft of the

security deposit in respect of the previous licence

Amount of previous security ‐deposit

No. and date of the demand draft of the balance of security deposit,

if any, required on the fresh contract

(5) (6) (7) No. and date of certificate

of registration of the establishment in relation to which the new licence

is applied for

Name and address of the principal employer

Particulars of fresh contract

Remarks

(8) (9) (10) (11) Place :

Signature of the Applicant. Date :



FORM VI [See Rule 25(1)]

Government of India

OFFICE OF LICENSING OFFICER Licence No. Dated Fee paid Rs ..................

License

1. Licence is hereby granted to ......................... under Section 12(1) of the Contract Labour (regulation and Abolition) Act, 1970, subject to the conditions specified in Annexure.

2. This licence is for doing the work of (nature of work to be indicated) in the

establishment of________(name of principal employer to be indicated) at______(place of work to be indicated).

3. The licence shall remain in force till__________(date to be indicated). Date……………………….. Signature and Seal of Licensing Officer

RENEWAL

[See Rule 29]

Date of renewal Fee paid for renewal Date of expiry 1. 2. 3.

Date. ........................ Signature and Seal of the Licensing Officer


C o m p i l e d b y P o w e r H R F o r u m P a g e - C 1 0

ANNEXURE TO FORM VI

The licence is subject to the following conditions— 1. The licence shall be non‐transferable. 2. The number of workmen employed as Contract Labour in the establishment shall

not, on any day, exceed. ........ 3. Except as provided in the rules the fees paid for the grant, or as the case may be,

for renewal of the licence shall be non‐refundable. 4. The rates of wages payable to the workmen by the contractor shall not be less

than the rates prescribed for the Schedule of employment under the Minimum Wages Act, 1948, where applicable, and where the rates have been fixed by agreement, settlement or award, not less than the rates fixed.

5. In cases where the workmen employed by the contractor perform the same or similar kind of work as the workmen directly employed by the principal employer of the establishment, the wage rates, holidays, hours of work and other conditions of service of the workmen of the contractor shall be the same as applicable to the workmen directly employed by the principal employer of the establishment on the same or similar kind of work: provided that in the case of any disagreement with regard to the type of work the same shall be decided by the [Deputy] Chief Labour Commissioner (Central), whose decision shall be final.

6. In other cases the wage rates, holidays, hours of work and conditions of service of the workmen of the contractor shall be such as may be specified in this behalf by the [Deputy] Chief Labour Commissioner (Central).

7. In every establishment where 20 or more women are ordinarily employed as contract labour there shall be provided two rooms of reasonable dimensions for the use of their children under the age of six years. One of such rooms would be used as a play‐room for the children and the other as bedroom for the children. For this purpose the contractor shall supply adequate number of toys and games in the play‐room and sufficient number of cots and beddings in the sleeping‐room. The standard of construction and maintenance of the creches may be such as may be specified in this behalf by the Chief Labour Commissioner (Central).

8. The licensee shall notify any change in the number of workmen or the conditions of work to the Licensing Officer.

9. A copy of the licence shall be displayed prominently at the premises where the contract work is being carried on.]

10. The licensee shall, within fifteen days of the commencement and completion of each contract work submit a return to the Inspector appointed under Section 28 of the Act intimating the actual date of the commencement or, as the case may be, completion of such contract work in Form VI‐A.]



FORM VI‐A [See Rule 25(2)(vm)]

Notice of Commencement/Completion of Contract Work

I/We, Shri/M/s. (Name and address of the contractor) hereby intimate that the contract work (Name of work). ……... in establishment of the ...................... (Name and address of principal employer). ............... for which licence No ....................... dated ..................has been issued to me/us by the Licensing Officer (name of the headquarters), has been commenced/completed with effect from (date) /on (date). To

Signature of Contractors) The Inspector, …………………….. …………………………



FORM VI‐B [See Rule 81(3)]

Notice of Commencement/Completion of Contract work

1. Name of the principal employer and address ........... 2. No. and date of certificate of Registration ........... 3. I/We hereby intimate that the contract work (Name of work) given to (name

and address of the contractor) having licence No ..................... dated ............................. has been commenced/completed with effect from (date)/on (date).

Signature of the Principal Employer

To The Inspector, …………………….. …………………………



FORM VII [See Rule 29(2)]

Application for Renewal of License 1. Name and address of the contractor. 2. Number and date of the licence. 3. Date of expiry of the previous licence. 4. Whether the licence of the contractor was suspended or revoked. 5. Name of the Bank, number and date of the demand draft enclosed. Date of

receipt of the application with demand draft number and date. Place ...................

Date ..................... Signature of the Applicant

(To be filled in the Office of the Licensing Officer)

Date of receipt of the application with Treasury Receipt No. and date.

Signature of the Licensing Officer



FORM VIII [See Rule 32(2)]

Application for Temporary Registration of Establishment Employing Contract Labour

1. Name and location of the establishment. 2. Postal address of the establishment. 3. Full name and address of the Principal Employer (furnish fatherʹs name in the

case of individuals). 4. Full name and address of the Manager or person responsible for the supervision

and control of the establishment. 5. Nature of work carried on in the establishment. 6. Particulars of contract labour:

A. Nature of work in which contract labour is to be employed and reasons for urgency.

B. Maximum number of contract labour to be employed on any day. C. Estimated date of termination of employment of contract labour.

7. Particulars of demand draft enclosed (name of the Union Bank, demand draft No. and date).


Principal Employer Seal and Stamp

Time and date of receipt of application with Treasury Receipt [* *] .




FORM IX [See Rule 32(3)]

Temporary Certificate of Registration

No. Date of Expiry …............. Date

Government of India Office of the Registering Officer

A Temporary Certificate of Registration containing the following particulars is hereby granted under sub‐section (2) of Section 7 of the Contract Labour (Regulation and Abolition) Act, 1970, and the rules made thereunder, to ............................. valid from ................... ..... to ............................

1. Nature of work carried on in the establishment. 2. Nature of work in which Contract Labour is to be employed. 3. Maximum number of Contract Labour to be employed on any day. 4. Other particulars relevant to the employment of Contract Labour.

Signature of Registering Officer with Seal



FORM X [See Rule 32(2)]

Application for Temporary Licence 1. Name and address of the contractor (including his fatherʹs name in case of

individuals). 2. Date of birth and age (in case of individuals). 3. Particulars of Establishment where Contract Labour is to be employed—

a) Name and address of the Establishment. b) Type of business, trade, industry, manufacture or occupation, which is carried on

in the establishment. c) Name and address of the Principal Employer.

4. Particulars of Contract Labour— a) Nature of work in which Contract Labour is to be employed in the establishment. b) Duration of the proposed contract work (give particulars of proposed date of

commencing and ending). c) Name and address of the Agent or Manager of Contractor at the work‐site. d) Maximum number of Contract Labour proposed to be employed in the

establishment on any day. 5. Whether the contractor was convicted of any offence within the preceding five years.

If so, give details. 6. Whether there was any order against the contractor revoking or suspending licence

or forfeiting security deposits in respect of an earlier contract. If so, the date of such order.

7. Whether the contractor has worked in any other establishment within the past five years. If so, give details of the Principal Employer, Establishments and nature of work.

8. Amount of licence fee paid—name of the Union Bank, demand draft No. and date. 9. Amount of security deposit—name of the Union Bank, demand draft No. and date.

Date of the receipt of the application with demand draft for fees/security deposits. Place…………… Signature of the Applicant Date ……………

(Contractor)

(To be filled in the Office of the Licensing Officer) Date of receipt of the application with challan for fees . . . . . . . . . Security Deposit




FORM XI [See Rule 32(3)]

Government of India

OFFICE OF THE LICENSING OFFICER

Licence No. Dated Fee paid Rs … … … … … …

Signature of the Licensing Officer Temporary Licence Expires on . . . . . . . . .

Licence is hereby granted to . . . . . . . . . . . under Section 12(2) of the Contract Labour (Regulation and Abolition) Act, 1970, subject to the conditions specified in Annexure. The Licence shall remain in force till . . . . . . . . . . . . . . . . . . . .

Date . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature and Seal of the Licensing Officer ANNEXURE

The licence is subject to the following conditions:— 1) The licence shall be non‐transferable. 2) The number of workmen employed as Contract Labour in the establishment

shall not, on any day, exceed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3) Except as provided in the rules the fees paid for the grant of the licence shall

be non‐refundable. 4) The rates of wages payable to the workmen by the contractor shall not be less

than the rates prescribed for the Schedule of employment under the Minimum Wages Act, 1948, where applicable, and where the rates have been fixed by agreement, settlement or award, not less than the rates fixed.

5) In cases where the workmen employed by the contractor perform the same or similar kind of work as the workmen directly employed by the principal employer of the establishment, the wage rates, holidays, hours of work and other conditions of service of the workmen of the contractor shall be the same as applicable to the workmen directly employed by the principal employer of the establishment on the same or similar kind of work: Provided that in the case of any disagreement with regard to the type of work the same shall be decided by the [Deputy] Chief Labour Commissioner (Central), whose decision shall be final.

6) In other cases the wage rates, holidays, hours of work and conditions of service of the workmen of the contractor shall be such as may be specified in this ʹbehalf by the Chief Labour Commissioner (Central).

7) A copy of the licence shall be displayed prominently at the premises where the contract work is being carried on.



FORM XII [See Rule 74]

Register of Contractors

1 . Name and address of the Principal Employer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Name and address of the establishment .................................

Sl No. Name and address of contractor

Nature of work on contract

Location of contract work

Period of contract

Maximum No. of

workmen employed by contractor

From To

Place …………………….. Date ………………………




FORM XIII

[See Rule 75] Register of Workmen Employed by Contractor

Name and address of Contractor .......................................................

Name and address of establishment in/under which............................................ contract is carried on .............. .....

Nature and location of work .................................................................

Name and address of Principal Employer………………………………………………………………………………………………………..

SI. No.

Name and surname of workman

Age and Sex


Nature of Employment/ Designation

Permanent Home Address of

workman(Village and Tahsil/Taluk and District)

1 2 3 4 5 6

Local Address

Date of commencement of employment

Signature or thumb‐

impression of workman


Reasons for termination

Remarks

7 8 9 10 11 12



FORM XIV [See Rule 76]

Employment Card

Name and address of Contractor ………………………………………………

Name and address of Establishment in/under which contract is carried on……….. ……………………...…………………………..……..

Nature of work and location of work ……………………………………………. …………...................................................

Name and address of Principal Employer….. ……………………...…………………………..……..

1. Name of the workman .................................................................................... 2. SI. No. in the register of workmen employed

…………………………………………………….. 3. Nature of employment/Designation ............................................................................ 4. Wage rate (with particulars of unit, in case of piece‐work) ............................... 5. Wage period ...................................................................................... 6. Tenure of employment ...................................................................................... 7. Remarks ........................................................................................................

Signature of Contractor



FORM XV [See Rule 77]

Service Certificate Name and address of contractor ……………………………

Name and address of establishment in/under which contract is carried on .............................................

Nature and location of work. ……………………………

Name and address of Principal Employer………………………………………….

Name and address of the work‐man………………….……………………………

Age or Date of Birth ……………………………

Identification Marks ……………………………

Fatherʹs/Husbandʹs name ……………………………

SI. No Total period for

which employed Nature of work

done Rate of wages

(with particulars of unit in case of piece‐work)

Remarks

From To

1 2 3 4 5 6



FORM XVI [See rule 78(l)(a)(i)] Muster roll

Name and address of Contractor…………………..

Name and address of establishment in/under which contract is carried on…………………...…………………………...…………………………………………………

Nature and location of work………………………………

Name and address of Principal Employer……………………………………………………………………………………………………………………………………………………………………………………………… For the month of ……………………………………………………………………………………………………

Sl. No.

Name of workman

Father’s/Husband’s Name

Sex Dates Remarks 1 2 3 4 5



FORM XVII [See Rule 78(1)(a)(i)] Register of Wages

Name and Address of Contractor………………………………… ……………………………………………….

Name and address of Establishment in/under which contract is carried on……………………………………….. ……………………………………………

Nature and location of work ……………………………………………

………………………………………………. Name and address of Principal Employer ………………………………. …………………………………………… Wage period Monthly ………………….

SI. No.

Name of workman

Serial No. in the register of workmen

Designation/ nature of work done

No. of days worked

Units of work done

1 2 3 5 6 7

Daily‐rate of wages/piecerate

Amount of wages earned Basic wages

Dearness Allowances

Overtime Other cash payments(Nature of payment to be

indicated)

Total

7 8 9 10 11 12

Deductions, if any (indicate nature)

Net amount paid Signature/Thumb‐ impression of workman

Initial of contractor or his representative

13 14 15 16



FORM XVII [See Rule 78(1)(a)(i)]

Form of Register of Wages‐cum‐Muster Roll Name and address of Contractor ………………………………………….

Name and address of establishment in/under which contract in carried on………………………………………….. Name and address of Principal Employer……………………………………. ……………………………………………….. Wage period: Weekly/Fortnightly ………….

Nature and location of work …………………..

From ……………… to ……………………..

SI. No.

SI. No. in Register of workmen

Name of employee

Designation/ nature of work

Daily attendance units worked

Total attendances/units of

work done 1 2. .15

1 2 3 4 5 6 Daily‐rate of wages/piece‐

rate

Amount of wages earned Basic wages

Dearness Allowance

Overtime

Other cash payments (nature of payments to be

indicated)

Total

7 8 9 10 11 12

Deduction, if any, (indicate nature)

Net amount paid

Signature/Thumb‐impression of workman

Initials of contractor or his representative

13 14 15 16



FORM XIX

(See Rule 78 (1) (b) Wage Slip

Name and Address of Contractor………………….

…………………………………………………… ………………………………………………….. Nature and location of work ……………………… …………………………………………………… ……………………………………………………

Name and Fatherʹs/Husbandʹs name of the workman .…………………...………………… ……………………………………………………For the Week/Fortnight/Month ending………. ……………………………………………………………………………………………………………………………………………………………………………………………………………………

1. No. of days worked ………………………………………………………………………. 2. No. of units worked in case of piece‐rate Workers……………………………………… 3. Rate of daily wages/pieces‐rate ………………………………………………………….. 4. Amount of overtime wages ………………………………………………………………... 5. Gross wages payable ……………………………………………………………………….. 6. Deductions, if any …………………………………………………………………………… 7. Net amount of wages paid …………………………………………………………………..

Initials of the Contractor or his Representative



FORM XX (See Rule 78 (1) (a) (ii)

Register of Deductions for Damage or Loss Name and Address of Contractor ………… ………………………………………………... Nature and Location of work ……………… ………………………………………………...

Name and Address of Establishment in/under which contract is carried on ………………………………………… ………………………………………… Name and Address of Principal Employer ……………………………. …………………………………………

Sl. No.

Name of workman

Father’s/ husband’s name

Designation/Nature of employmen

t

Particulars of damage or loss

Date of Damage or loss

Whether workman

showed cause against deduction

1 2 3 4 5 6 7

Name of person in whose presence

employee’s explanation was

heard

Amount of deduction imposed

No. of installments

Date of Recovery First

installment

Last installment

Remarks

8 9 10 11 12 13



FORM XXI [See Rule 78(1) (a)(ii)] Register of Fines

Name and Address of Contractor …………………………………………………..

Name and Address of Establishment in/under which contract is carried on ……………………………………….. ………………………………………..

Nature and location work …………………………………………………..

Name and Address of Principal Employer ……………………………... ………………………………………….

Sl. No.

Name of workman


Designation/Nature of employment

Act Omission for which fine imposed

Date of offence

1 2 3 4

5 6

Whether work‐man showed cause against

fine

Name of person in whose presence employeeʹs

explanation was heard

Wage periods and

wages payable

Amount of fine imposed

Date on which fine realized

Remarks

7 8 9 10 11 12



FORM XXII [See Rule 78(1) (a)(ii)] Register of Advances



Nature and location work …………………………………………………..


Sl. No.

Name Father’s/ husband’s name

Nature of employment/Designation

Wage period and wages payable

Date and amount of

advance given 1 2 3 4 5 6

Purpose(s) for which advance

made

No. of installments by which advance to be repaid

Date and amount of

each installment repaid

Date on which last installment was repaid

Remarks

7 8 9 10 11



FORM XXIII [See Rule 78(1) (a)(iii)] Register of Overtime



Nature and location work ………………………………………………….


Sl. No.

Name of workman


Sex Designation/nature of

employment

Date on which overtime worked

1 2 3 4 5 6


production in case

of piece‐rated

Normal rates of wages

Overtime rate of wages

Overtime earnings

Date on which

overtime wages paid

Remarks

7 8 9 10 11 12



FORM XXIV [(See Rule 82 (1)]

Return to be Sent by the Contractor to the Licensing Officer

Half‐Year‐Ending .....................

1. Name and address of the Contractor 2. Name and address of the establishment 3. Name and address of the Principal employer 4. Duration of contract: From ................ to ……. 5. No. of days during the half‐year on which—

a. the establishment of the principal employer had worked b. the contractorʹs establishment had worked

6. Maximum number of contract labour employed on any day during the half year: Men Women Children Total 7.

i. Daily hours of work and spread over— ii.

a) whether weekly holiday observed and on what day— b) if so, whether it was paid for—

iii. No. of man‐hours of overtime worked— 8. Number of man‐days worked by— Men Women Children Total 9. Amount of wages paid— Men Women Children Total 10. Amount of deductions from wages, if any— Men Women Children Total 11. Whether the following have been provided—

i. Canteen……………….. ii. Rest‐Rooms ………….. iii. Drinking‐water………… iv. Creches……………….. v. First‐Aid………………..

(If the answer is ʹyesʹ state briefly standards provided) Place Date Signature of Contractor



FORM XXV [See Rule 82(2)]

Annual Return of Principal Employer to be Sent to the Registering Officer

Year ending 31st December, 19. ...............

1. Full name and address of the Principal Employer. 2. Name of Establishment:

a) District b) Postal Address c) Nature of operation/industry/work carried on.

3. Full name of the Manager or person responsible for supervision and control of the establishment.

4. Number of contractors who worked in the establishment during the year (Give details in Annexure).

5. Nature of work/operations on which contract labour was employed. 6. Total number of days during the year on which contract labour was employed. 7. Total number of man‐days worked by contract labour during the year. 8. Maximum number of workmen employed directly on any day during the year. 9. Total number of days during the year on which direct labour was employed. 10. Total number of man‐days worked by directly‐employed workmen. 11. Change, if any, in the management of the establishment, its location, or any other

particulars furnished to the Registering Officer in the application for Registration indicating also the dates.

Principal Employer

Place ……………… Date ……………….



ANNEXURE TO FORMXXV

Name and Address of

the Contractor

Period of contract

Nature of work

Maximum number of workers

employed by each contractor

No. of days worked

No. of man‐days worked

From ….. To

1 2 3 4 5 6



[ANNEXURE ‘A’] [Rule 38(1)]

Sl. No. Officers Headquarters of the Officers

1 2 3

1 ALC(C) Delhi Delhi

2 ALC(C) Ajmer Ajmer

3 ALC(C) Ajmer Ajmer

4 ALC(C) Adipur Adipur

5 RLC(C) Asansol Asansol

6 ALC(C) Asansol Asansol

7 RLC(C) Bombay Bombay

8 ALC(C) Bombay Bombay

9 ALC(C) Nagpur Nagpur

10 ALC(C) Vasco –Da‐Gama Vasco –Da‐Gama

11 RLC(C) Calcutta Calcutta

12 ALC(C) Calcutta Calcutta

13 RLC(C) Gauhati Gauhati

14 RLC(C) Dhanbad Dhanbad

15 ALC(C) Dhanbad Dhanbad

16 ALC(C) Chaibasa Chaibasa

17 ALC(C) Hazaribagh Hazaribagh

18 RLC(C) Hyderabad Hyderabad

19 ALC(C) Hyderabad Hyderabad

20 ALC(C) Vijaywada Vijaywada

21 ALC(C) Visahakhapatnam Visahakhapatnam

22 RLC(C) Jabalpur Jabalpur

23 ALC(C) Jabalpur Jabalpur

24 ALC(C) Raipur Raipur

25 ALC(C) Shahdol Shahdol

26 RLC(C) Kanpur Kanpur

27 ALC(C) Kanpur Kanpur

28 RLC(C) Chandigarh Chandigarh



29 RLC(C) Bhubaneswar Bhubaneswar

30 ALC(C) Bhubaneswar Bhubaneswar

31 RLC(C) Madras Madras

32 ALC(C) Madras Madras

33 ALC(C) Ernakulam Ernakulam

34 RLC(C) Bangalore Bangalore

35 ALC(C) Bellary Bellary

36 ALC(C) Dehradun Dehradun

37 ALC(C) Rohtak Rohtak

38 ALC(C) Jagdalpur Jagdalpur

39 ALC(C) Jaipur Jaipur

40 ALC(C) Kplar Gold Fields Kplar Gold Fields

Forms under INTER‐STATE MIGRANT WORKMEN (REGULATION OF EMPLOYMENT AND CONDITION


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ D 1

Forms under

INTER‐STATE MIGRANT WORKMEN (REGULATION OF EMPLOYMENT AND CONDITION OF SERVICE) CENTRAL RULES, 1980




INDEX FORM I Application for Registration of Establishments Employing Migrant

Workmen FORM II Certificate of Registration FORM III Register of Establishments FORM IV Application for Licence for Recruitment FORM V Application for Licence for Employment FORM VI Form of Certificate by Principal Employer FORM VII Form of Certificate by Principal Employer FORM VIII Application for Adjustment of Security Deposit FORM IX Application for Renewal of Licence FORM X Particulars in Respect of Recruitment and Employment of Migrant

Workman/Workmen FORM XI Return to be Sent by the Contractor to the Authorities Specified under

Explanation below Sub‐Section (2) of Section 12 FORM XII Register of Contractors FORM XIII Register of Workmen Employed by Contractor FORM XIV Service Certificate FORM XV Displacement and Outward Journey Allowance Sheet FORM XVI Return Journey Allowance Register FORM XVII Muster Roll FORM XVIII Register of Wages FORM XIX Register of Deduction for Damage or Loss FORM XX Register of Fines FORM XXI Register of Advances FORM XXII Register of Overtime FORM XXIII Return to be Sent by the Contractor to the Licensing Officer FORM XXIV





FORM I [See rule 3(1)]

Application for Registration of Establishments Employing Migrant Workmen

1. Name and location of the establishment.

2. Postal Address of the establishment.

3. Full name and address of the principal employer (furnish father’s/husband’s name in the case of individuals).

4. Names and addresses of the directors/particular partners (in case of companies and firms).

5. Full names and address of the Manager or person responsible for the supervision and control of the establishment.

6. Nature of work carried on in the establishment.

7. Particulars of contractors and migrant workmen.

a. Names and addresses of contractors.

b. Nature of work for which migrant workmen are to be recruited or are employed.

c. Maximum number of migrant workmen to be employed on any day through each contractor.

d. Estimated date and commencement of work under each contractor.

e. Estimated date of termination of employment of migrant workmen under each contractor.

8. Particulars of crossed demand draft ________ (Name of the Bank, Amount, Number and Date)


Principal Employer

Seal and Stamp


Date of receipt of application:




FORM II [See rule 4(1)]

Certificate of Registration Date ________________________

GOVERNMENT OF INDIA


A certificate of registration containing the following particulars is hereby granted under clause (a) of sub‐section (2) of section 4 of the Inter‐State Migrant Workmen (Regulation of Employment and Conditions of Service) Act, 1979 and the rules made thereunder to......................

1. Nature of work carried on in the establishment.

2. Names and addresses of the contractors.

3. Nature of work for which migrant workmen are to be employed or are employed.

4. Maximum number of migrant workmen to be employed on any day through each contractor.

5. Other particulars relevant to the employment of migrant workmen.

(i)

(ii)

Signature of Registering

Officer with Seal




FORM III [See rule 4(2)]


Particulars of Contractor and Inter‐State migrant work

Sl. N

o.

Registratio

n No. and date

Nam

e an

d ad

dress of th

e establishm

ent registered

Nam

e of th

e Principa

l Em

ploy

er and his add

ress

Type

s of business, trad

e,

indu

stry, m

anufacture or

occupa

tion, w

hich is

carried on in th

e establishm

ent

Maxim

um N

o. of m

igrant

workm

en directly

employ

ed on an

y da

y

Nam

e an

d ad

dress of

contractor

Nature of w

ork for w

hich

migrant w

orkm

en are to

be re

cruited or are

employ

ed

Maxim

um N

o. of m

igrant

workm

en employ

ed on

any da

y throug

h a

contractor

Prob

able duration of

employ

ment o

f migrant

workm

en

Remarks

1 2 3 4 5 6 7 8 9 10 11




FORM IV [See rule 7(1)]

Application for Licence for Recruitment 1. Name and address of the contractor (including his father’s/ husband’s name in case of individuals.) 2. Date of birth and age (in case of individuals). 3. Particulars of establishment where migrant workmen are to be employed.

a. Name and address of the establishment;

b. Type of business, trade, industry manufacture or occupation, which is carried on in the establishment;

c. Number and date of certificate of registration of the establishment under the Act;

d. Name and address of the principal employer. 4. Particulars of migrant workmen:

a. Nature of work in which migrant workmen are employed or are to be employed in the establishment.

b. Duration of the proposed contract work (give particulars of proposed date of commencing and ending).

c. Name and address of the agent or manager of the contractor at the work‐site.

d. Maximum number of migrant workmen proposed to be employed in the establishment on any day.

e. Names and addresses of the directors/partners (in case of companies and firms).

f. Name(s) and address(es) of the person(s) in charge of and responsible to the company/firm, for the conduct of the business of the company/firm, as the case may be.

5. Whether the contractor was convicted of any offence within the preceding five years. If so, give details. 6. Whether there was any order against the contractor revoking or suspending licence or forfeiting

security deposits in respect of an earlier contract. If so, the date of such order. 7. Whether the contractor has worked in any other establishment within the past five years. If so, give

details of the principal employer, establishment, and nature of work. 8. Whether a certificate by the principal employer in Form VI is enclosed. 9. Amount of licence fee paid....................No. of crossed demand draft and date. 10. Amount of security deposit, if any.




DECLARATION I hereby declare that the details given above are correct to the best of my knowledge and belief.

Place............................ Date............................

Signature of the Applicant (Contractor)

Note.— The application should be accompanied by a crossed demand draft showing the payment of the prescribed licence fee and security deposit, if any and a certificate in Form V from the Principal Employer.

(To be filled in the office of the Licensing Officer)

Date of receipt of the application with crossed demand draft for fees. Signature of the Licensing Officer




FORM V [See rule 7(2)]

Application for Licence for Employment 1. Name and address of the contractor (including his father’s/ husband’s name in case of individuals.) 2. Date of birth and age (in case of individuals). 3. Particulars of establishment where migrant workmen are to be employed.

a. Name and address of the establishment;

b. Type of business, trade, industry manufacture or occupation, which is carried on in the establishment;

c. Number and date of certificate of registration of the establishment under the Act;

d. Name and address of the principal employer. 4. Particulars of migrant workmen:

a. Nature of work in which migrant workmen are employed or are to be employed in the establishment.

b. Duration of the proposed contract work (give particulars of proposed date of commencing and ending).

c. Name and address of the agent or manager of the contractor at the work‐site.

d. Maximum number of migrant workmen proposed to be employed in the establishment on any day.

e. Names and addresses of the directors/partners (in case of companies and firms).

f. Name(s) and address(es) of the person(s) in charge of and responsible to the company/firm, for the conduct of the business of the company/firm, as the case may be.

5. Whether the contractor was convicted of any offence within the preceding five years. If so, give details. 6. Whether there was any order against the contractor revoking or suspending licence or forfeiting

security deposits in respect of an earlier contract. If so, the date of such order.

7. Whether the contractor has worked in any other establishment within the past five years. If so, give details of the principal employer, establishment, and nature of work.

8. Whether a certificate by the principal employer in Form VI is enclosed.

9. Amount of licence fee paid......................No. of crossed demand draft and date.

10. Amount of security deposit, if any. DECLARATION

I hereby declare that the given are correct to the best of my knowledge and belief. Place......................... Date......................... Signature of the Applicant




(Contractor) Note.—The application should be accompanied by a crossed demand draft showing the payment of the

prescribed fee and security deposit, if any, and a certificate in Form VI from the principal employer. (To be filled in the office of the Licensing Officer)

Date of receipt of the application with crossed demand draft for fees.




C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ D 1 0

FORM VI [See rule 7(3)]

Form of Certificate by Principal Employer Certified that I have engaged the applicant (Name of the contractor) as a contractor in my establishment. I undertake to be bound all the provisions of the Inter‐State Migrant Workman (Regulation of Employment and Conditions of Service) Act, 1979 and the Inter‐State Migrant Workmen (Regulation of Employment and Conditions of Service) Central Rules, 1980 in so far as the provisions are applicable to me in respect of the employment of migrant workmen by the applicant in my establishment.

Place........................... Signature of Principal Employer Date............................. Name and address of establishment




FORM VII [See rule 10(3)]

Application for Adjustment of Security Deposit

Nam

e an

d ad

dress of th

e Con

tractor

Num

ber a

nd date of app

lication for fresh licence.

Date of exp

iry of previou

s licence

Whether th

e previous licence of th

e contractor

was suspe

nded or revok

ed.

Num

ber a

nd date of th

e crossed de

man

d draft

of security dep

osit in re

spect o

f the previou

s licence.

Amou

nt of p

reviou

s security dep

osit.

Amou

nt of security dep

osit for fresh licence

Num

ber a

nd date of crossed dem

and draft o

f the balance security dep

osit de

posited with

the fresh ap

plication

Num

ber a

nd date of certificate of re

gistratio

n of th

e establishm

ent in relatio

n to w

hich th

e fresh licence is app

lied

Nam

e an

d ad

dress of th

e principa

l employ

er

Particulars of fresh ap

plication

Remarks

1 2 3 4 5 6 7 8 9 10 11 12

Place................... Signature of applicant Date.....................




FORM VIII [See rule 11(1)]

GOVERNMENT OF INDIA

Office of Licensing Officer

Licence No. Dated Fee paid Rs.

Licence Licence is hereby granted to ............. under section 8(1) of the Inter‐State Migrant Workmen (Regulation of Employment and Conditions of Service) Act, 1979 subject to the conditions specified in the annexure.

2. This licence is for doing the work of (nature of work to be indicated) in the establishment of (name of principal employer to be indicated) at (place of work to be indicated).

3. The licence shall remain in force till (date to be indicated).

Signature and Seal of Licensing Officer.

RENEWAL

[See rule 14)

Date of renewal Fee paid for renewal

Date of expiry.

1

2

3

Date..........................

Signature and Seal of Licensing Officer




ANNEXURETO FORM VIII

The licence is subject to the following conditions:—

1. The licence shall be non‐transferable.

2. The number of workmen employed as migrant workmen in the establishment shall not, on any day, exceed the maximum number specified in the application for licence.

3. Save as provided in these rules the fees paid for the grant or as the case may be, for renewal of licence shall be non‐refundable.

4. The rates of wages payable to the migrant workmen by the contractor shall not be less than the rates prescribed under the Minimum Wages Act, 1948, for such employment where applicable, and where the rates have been fixed by agreement, settlement or award, not less than the rates so fixed.

5.

a. In case where the migrant workmen employed by the contractor perform the same or similar kind of work as the workmen directly employed by the principal employer of the establishment, the wage rates, holidays, hours of work and other conditions of service of the migrant workmen of the contractor shall be the same as applicable to the workmen directly employed by the principal employer of the establishment on the same or similar kind of work:

Provided that in the case of any disagreement with regard to the type of work, the same shall be decided by the Deputy Chief Labour Commissioner (Central) whose decision shall be final;

b. in other cases the wage rates, holidays, hours of work, and conditions of service of the migrant workmen of the contractor shall be such as prescribed in these rules.

6. Every migrant workmen shall be entitled to allowances benefits, facilities, etc., as prescribed in the Act and these rules.

7. No female migrant workmen shall be employed by any contractor before 6 am. or after 7 p.m.:

Provided that this clause shall not apply to the employment of female migrant workmen in pit head baths, creches and canteens and as midwives and nurses in hospitals and dispensaries.

8. The contractor shall notify any change in the number of migrant workmen or the conditions of work to the licensing officer.

9. The contractor shall comply with all the provisions of the Act and these Rules.

10. A copy of licence shall be displayed prominently at the premises where the migrant workmen are employed.




FORM IX [See rule 15(2)]

Application for Renewal of Licence 1. Name and address of the contractor. 2. Number and date of the licence. 3. Date of expiry of the previous licence. 4. Whether the licence of the Contractor was suspended or revoked. 5. Number and date of the crossed demand draft enclosed.

Place......................... Signature of the Applicant Date........................

(To be filled in the Office of the Licensing Officer) Date of receipt of the application with crossed demand draft No. and date.





FORM X (See rule 21)

Form in which to furnish particulars in respect of recruitment and employment of migrant workman/workmen as prescribed under sub‐rule (1) of rule 21, to the authorities specified under the Explanation below sub‐section (2) of section 12 of Inter‐State Migrant Workmen (Regulation of

Employment and Conditions of Service) Act, 1979

1. Name and address of the Contractor……………………………………………………………………. 2. Name and address of the sub‐contractor through whom recruitment has been made…………….. 3. Name and address of the establishment…………………………………………………………………. 4. Name and address of the Principal Employer…………………………………………………………… 5. Name of the State in which the place of work is located……………………………………………….. 6. Name of the State in which recruitment was made………………………………………………………

Serial num

ber

Nam

e of m

igrant

workm

an.

Father’s/H

usband

’s

Nam

e Sex.

Age

Perm

anent h

ome

address.

Nam

e an

d ad

dress of

the next of k

in

of th

e migrant

workm

an.

Place an

d ad

dress of

reside

nce in th

e ho

me State.

Amou

nt of d

isplacem

ent

allowan

ce

paid.

1 2 3 4 5 6 7 8 9

Amou

nt of o

utward

journey

allowan

ce paid.

Amou

nt of w

ages fo

r ou

tward

journey pe

riod paid.

Nature of job requ

ired to

be

performed

. Date of re

cruitm

ent

Date of employ

ment

Details of rates of w

ages

and other a

llowan

ces

payable

Period of con

tract o

f em

ploy

ment

Details of o

ther service

cond

ition

s Remarks

10 11 12 13 14 15 16 17 18

Signature of Contractor or his authorised representative




Date..........................

Submitted to 1. ........................................... .......................................... (Specified authority in the State from which the migrant workman/workmen is/are employed). 2. ........................................... .......................................... (Specified authority in the State in which migrant workman/workmen has/have been recruited.) Copy forwarded to .......................................... (The Principal Employer)

Signature of the Contractor or his authorised representative.

Date.......................... Note.—In case where migrant workmen concerned have been recruited from more than one State, separate returns shall be submitted in respect of each such State.




FORM XI (See rule 24)

Return to be sent by the contractor to the authorities specified under Explanation below sub‐section (2) of section 12 of Inter‐State Migrant Workmen (Regulation of Employment and Conditions of

Service) Act, 1979

1. Name and address of the Contractor…………………………………………………………… 2. Name and address of the sub‐contractor through whom recruitment has been made…….. 3. Name and address of the establishment………………………………………………………………….. 4. Name and address of the Principal Employer………………………………………………………….. 5. Name of the State in which the place of work is located………………………………………………. 6. Name of the State in which recruitment was made……………………………………………………..

Serial N

o.

Nam

e of m

igrant w

orkm

an

Father’s/H

usband

’s nam

e Sex Designa

tion

Age

Perm

anent h

ome ad

dress

indicatin

g the State

Place an

d ad

dress of

reside

nce

in hom

e State

Date of employ

ment

Date on w

hich ceased to be

employ

ed

Total d

ays worked

1 2 3 4 5 6 7 8 8 19 11

Details of rates of w

ages

and other

allowan

ces pa

id.

Amou

nt of d

isplacem

ent

allowan

ce

paid.

Amou

nt of o

utward

journey

allowan

ces an

d wages fo

r ou

tward journey pa

id.

Amou

nt of return journey

allowan

ces

and wages fo

r return

journey pa

id.

Total w

ages paid.

Details of com

pensation

and other

allowan

ces.

Amou

nt of d

eductio

ns, if

any.

Amou

nt of a

dvan

ce, if a

ny

paid.

Amou

nt of a

dvan

ce, if a

ny

recovered.

Remarks.

DECLARATION I/We hereby declare that all wages, other dues including displacement allowance, outward return journeys allowances and wages for journeys period payable to migrant workman/workmen named above and employed by me/us have been paid by me/us to him/them. Place.......................... Date...........................

Signature of the Contractor or his




authorised representative Submitted to (1) ................................ ................................. (Specified authority in the State in which migrant workman/workmen is/are employed). (2) ................................ ................................ (Specified authority in the State in which migrant workman/workmen has/have been recruited.) Copy forwarded to

........................................ (The Principal Employer)

Signature of the Contractor or his

authorised representative. Date.................... Note.—In case where migrant workmen concerned have been recruited from more than one State, separate returns shall be submitted in respect of each such State.




FORM XII [See Rule 48]

Register of Contractors

1. Name and Address of the principal employer

2. Name and address of the establishment

Name and address of the contractor

Nature of work on contract

Location of contract work

Period of contract`

Maximum number of migrant workmen employed by contractor

From To




FORM XIII [See Rule 49]

Register of Workmen Employed by Contractor Name and address of contractor …………………………….

Name and address of establishment in/under which migrant workmen are employed……………………………

Name and address of establishment ………………………..

Name and address of Principal Employer………………………………………..

Sl No. Name

and surname of migrant workman

Age and sex

Father’s /Husband’s name

Nature of employment/ designation

Permanent home adderss of migrant workmen, village and Tehsil/Taluk and district

Local address

Date of commencement of employement

1 2 3 4 5 6 7 8

Signature and thumb impression of migrant workmen


Reasons for termination Remarks

9 10 11 12

Signature of contractor or his authorized representative




FORM XIV (See rule 50)

Service Certificate Name and address of Contractor………..

Name and address of establishment in/under which migrant workmen are

employed………………………

Nature and location of work………… Name and address of Principal Employer………………..

Name and address of the migrant workman……..

Age or date of birth…………………

Identification marks…………………..

Father’s/Husband’s name………………..

Serial No.

Total period for which employed Nature of work done

Rate of wages (with particulars of unit in case of piece work)

Remarks

From To

1 2 3 4 5 6





FORM XV [See rule 51(1)]

Displacement and Outward Journey Allowance Sheet

Name and address of the Contractor…………………………………………………………. Name and address of the Principal Employer……………………………………………. Name and address of the establishment……………………………………………………… Month and Year………………………………………………………………………………..

Serial N

o.

Nam

e of th

e migrant w

orkm

an

Father’s/H

usband

’s nam

e Perm

anent h

ome ad

dress

indicatin

g the State

Place an

d ad

dress of re

side

nce in

home State

Designa

tion

Rate of w

ages

Wages payable in a m

onth

Place of re

cruitm

ent

Place of w

ork with add

ress

indicatin

g the State

Railw

ay Statio

n/Bu

s Stan

d nearest to the place of re

side

nce

Railw

ay Statio

n/Bu

s Stan

d nearest to the place of w

ork

Date an

d tim

e of com

mencement

of journey from th

e place of

reside

nce

1 2 3 4 5 6 7 8 9 10 11 12 13

Expe

cted date an

d tim

e of arrival at the

place of w

ork.

Details of m

odes of jou

rneys from th

e place

of re

side

nce in th

e ho

me State to th

e place

Amou

nts of bus fa

re and

/or secon

d class

train fare and

/or o

ther journey expe

nses

sepa

rately as the mod

es of jou

rney

indicated in colum

n (15).

Total o

f amou

nts indicated in colum

n No. (1

6).

Amou

nt of d

isplacem

ent a

llowan

ce.

Amou

nt of o

utward journey

allowan

ce.

Wages fo

r outward journey pe

riod

.

Total amou

nt paid.

Date on w

hich paid.

Sign

ature or th

umb‐im

pression of

the migrant w

orkm

an.

Actua

l date an

d tim

e of arrival at the

place of w

ork.

Balance wages fo

r outward journey,

if an

y, payable.

Date of payment o

f the balan

ce w

ages

indicated in colum

n (25).

Sign

ature or th

umb‐im

pression of

the migrant w

orkm

an.

Remarks.

14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Note.—Indicate separately different mode of journeys. Entries are to be made against each individual migrant workman.


Date........................




FORM XVI [See rule 51(1)]

Return Journey Allowance Register Name and address of the Contractor……………………………………… Name and address of the Principal Employer…………………………….. Name and address of the establishment……………………………………. Month and Year…………………………………………………………………

Serial N

o.

Nam

e of th

e migrant

workm

an

Father’s/H

usband

’s nam

e Perm

anent h

ome ad

dress

indicatin

g the State

Place an

d ad

dress of

reside

nce in hom

e State

Designa

tion

Rate of w

ages

Place of w

ork

Railw

ay Statio

n/Bu

s Stan

d nearest to the place of w

ork

Railw

ay Statio

n/Bu

s Stan

d nearest to the place of

reside

nce in th

e ho

me State

Date an

d tim

e of

commencement o

f jou

rney

from th

e place of w

ork

1 2 3 4 5 6 7 8 9 10 11

Expe

cted date an

d tim

e of arrival

at th

e reside

nce in th

e ho

me State

*Exp

ected of m

odes of jou

rneys

from th

e place of w

ork to place of

reside

nce in th

e ho

me State.

Amou

nt of b

us fa

re and

/or

second class train fare and

/or

other jou

rney exp

enses sepa

rately

as per exp

ected mod

es of jou

rney

indicated in colum

n (13)

Total o

f amou

nts indicated in

column No. (1

4)

Amou

nt of return journey

allowan

ce

Wages fo

r return journey pe

riod

Total amou

nt paid

Date on w

hich paid

Sign

ature or th

umb‐im

pression

of th

e migrant w

orkm

an

Remarks

12 13 14 15 16 17 18 19 20 21

* Indicate separately different modes of journey. Note.—Entries are to be made against each individual inter‐State migrant workman.


Date........................




FORM XVII [See rule 52(2)(a)] Muster Roll

Name and address of Contractor……………………………………………………………… Nature and location of work……………………………………………………………………. Name and address of establishment in/under which inter‐State migrant workmen are employed……………………............................................... Name and address of Principal Employer…………………………………………………. For the month of ............................................................................................................................

Serial Number Name of migrant workmen

Father’s / Husband’s Name

Sex Date Remarks

1 2 3 4 5




FORM XVIII [See rule 52(2)(a)]

Register of Wages

Name and address of Contractor……………………………………………………………. Nature and location of work……………………………………………………………….. Name and address of establishment in/under which inter‐State Migrant Workmen are employed……………………………………………….. Name and address of Principal Employer…………………………………….. Wage period………………………………………………………..

Serial N

o.

Nam

e of in

ter‐State migrant

workm

an

Serial N

o. in th

e register of

workm

en

Designa

tion/na

ture of w

ork

Num

ber o

f days worked

Units of w

ork do

ne

Daily ra

te of w

ages/ p

iecerate

Amount of wages earned

Total.

Ded

uctio

ns, if a

ny (ind

icate

nature)

Net amou

nt paid

S i g n a t u r e / T h u m b ‐

impression of Inter‐State

Migrant W

orkm

an

Initials of Con

tractor o

r his

authorised re

presentativ

e

Basic wages

Dearness allowan

ce

Overtim

e

Other cash pa

yments

(nature of payment to be

indicated)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16




FORM XIX [See rule 52(2)(c)]

Register of Deduction for Damage or Loss

Name and address of Contractor……………………………………………………. Nature and location of work………………………………………………………….. Name and address of establishment in/under which inter‐State migrant workmen are employed……………………………………………………………………………………. Name and address of Principal Employer……………………………………………………

Serial num

ber

Nam

e of in

ter‐State

migrant w

orkm

an.

Father’s/H

usband

’s

name

Designa

tion/na

ture of

employ

ment

Particulars of dam

age or

loss

Date of dam

age or lo

ss.

Whether in

ter‐State

migrant w

orkm

an

show

ed cau

se against

dedu

ction

Nam

e of person in w

hose

presence employ

ee’s

explan

ation was heard

Amou

nt of d

eductio

n im

posed

Num

ber o

f instalm

ents

Date of re

covery of first in

stalment

Date of re

covery of last instalm

ent

Remarks

1 2 3 4 5 6 7 8 9 10 11 12




FORM XX [See rule 52(2)(c)] Register of Fines

Name and address of Contractor………………………………………………………………… Nature and location of work……………………………………………… Name and address of establishment in/under which inter‐State migrant workmen are employed…………………………………………………………………………. Name and address of Principal Employer……………………………………….

Serial num

ber

Nam

e of in

ter‐State migrant

workm

an

Father’s/H

usband

’s nam

e Designa

tion/na

ture of

employ

ment

Act/O

mission fo

r which

fine im

posed

Date of offe

nce

Whether in

ter‐State

Migrant W

orkm

an sho

wed

cause against fine

Nam

e of person in w

hose

presence employ

ee’s

explan

ation was heard

Wages periods and w

ages

payable

Amou

nt of fine im

posed

Date on w

hich fine re

alised

Remarks

1 2 3 4 5 6 7 8 9 10 11 12




FORM XXI [See rule 52(2)(c)]

Register of Advances

Name and address of Contractor………………………………………………………………. Nature and location of work…………………………………………………………………… Name and address of establishment in/under which inter‐State migrant workmen are employed…………………………………………………………………………………… Name and address of Principal Employer………………………………………………………

Serial num

ber

Nam

e of In

ter‐State

Migrant

Workm

an

Father’s/H

usband

’s nam

e Nature of Employ

ment/

Designa

tion

Wage pe

riod and w

ages

payable

Date an

d am

ount of

advance given

Purpose(s) fo

r which

advance mad

e Num

ber o

f instalm

ents by

which adv

ance to be

repa

id

Date an

d am

ount of each

instalment rep

aid

Date on w

hich last

instalment

was re

paid

Remarks

1 2 3 4 5 6 7 8 9 10 11




FORM XXII [See rule 52(2)(d)]

Register of Overtime

Name and address of Contractor…………………………………………….. Nature and location of work……………………………………………………… Name and address of establishment in/under which inter‐State migrant workmen are employed.……………………………………………………………………. Name and address of Principal Employer……………………………………….

Serial num

ber

Nam

e of In

ter‐State Migrant

Workm

an

Father’s/H

usband

’s nam

e Sex Designa

tion/na

ture of

employ

ment

Date on w

hich overtim

e worked

Total o

vertim

e worked for

prod

uctio

n in case of

piecerated

Normal ra

tes of w

ages

Overtim

e rate of w

ages

Overtim

e earnings

Date on w

hich overtim

e wages paid

Remarks

1 2 3 4 5 6 7 8 9 10 11 12




FORM XXIII [See Rule 56(1)]

Return to be Sent by the Contractor to the Licensing Officer

Half year endings

1. Name and address of the contractor …………………………….

2. Name and address of establishment……………………………….

3. Name and address of principal employer……………………………..

4. Duration of contract : From…………. To…………..

5. No. of days during the half‐year on which……………….

a. The establishment of principal employer had worked……….

b. The contractor’s establishment had worked

6. Maximum number of inter‐state migrant workmen employed on any day during the half year

Men Women Children Total

7.

(i) Daily hours of work and spread over

(ii)

a. Whether weekly holiday observed and on what day

b. If so, whether it was paid for

(iii) No. of man‐hours of overtime worked

8. No. of man‐days worked by:


9. Amount of wages paid


Wages shall include wages for periods of outwards and return journey




10. Amount of deductions from wage, if any


11. Amount of displacement allowance paid


12. Amount of outward journey allowance paid


13. Amount of wages for outward journey period paid


14. Amount of return journey allowance paid


15. Amount of wages for return journey period paid


16. Whether the following have been provided

i) Residential accommodation; ii) Protective clothing; iii) Canteen; iv) Rest room; v) Latrine and urinals; vi) Drinking water; vii) Creche; viii) Medical facilities; ix) First‐aid

( If the answer is yes, state briefly nature/standards provided)

Place ………..

Date…………..

Signature of contractor




FORM XXIV [See rule 56(2)]


Year ending 31st December. 1. Full name and address of the Principal Employer: 2. Name of establishment:

a. District: b. Postal Address: c. Nature of operation/industry/work carried on:

3. Full name of the Manager or persons responsible for supervision and control of the establishment.

4. Number of contractors who worked in the establishment during the year (Give details in Annexure).

5. Nature of work/operations on which migrant workman was employed. 6. Total number of days during the year on which migrant workman was employed. 7. Total number of mandays worked for by migrant workman during the year. 8. Maximum number of workmen employed directly on any day during the year. 9. Total number of days during the year on which direct labour was employed. 10. Total number of mandays worked by directly employed workmen. 11. Change, if any, in the management of the establishment, its location, or any other particulars

furnished to the Registering Officer in the application for Registration indicating also the dates.

Place Principal Employer

Date

Annexure to Form

Name and address of the contractor

Period of contract

Nature of work

Maximum number of workers employed by each contractor

Number of days worked

Number of mandays worked

From

To

Forms under MINES RULES, 1955

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ E 1

Forms under

MINES RULES, 1955



INDEX FORM‐ A Notice of Commencement and End of Work

FORM ‐B Register of Employees ( See Rules 48(3), 51, 77 and 77.A(2)))

FORM ‐C Register of Persons Employed Below Ground During the Weak

FORM ‐D Register of Persons Employed Above Ground in Opencast Working During

the Week

FORM ‐E Register of Persons Employed Above Ground Otherwise than in Opencast

Working During the Week

FORM‐F Register of Compensatory Days of Rest

FORM‐G Register of Leave Account During the Calendar Year

FORM‐H Register of Leave Wages Account During the Calendar Year

FORM ‐I Register of Overtime Wages

FORM ‐J Report of Accident

FORM ‐K Return of Minor Accidents

FORM ‐L Information Regarding Leave with Wages

FORM‐M Notice of Initial/ Periodical Medical Examination Under Rule 29B

FORM ‐N Second and Final Notice of Initial/Periodical Medical Examination Under

Rule 29 B

FORM ‐O Report of Medical Examination Under Rule 29B

FORM ‐P Medical Standard of Fitness for Persons Employed

FORM ‐P‐I Medical Standard of Fitness for Persons to be Employed in Mines

FORM ‐Q Notice of Medical Re‐Examination by Appellate Medical Board

FORM ‐R Second and Final Notice of Medical Re‐Examination by Appellate Medical Board

FORM ‐S Report of Medical Re‐Examination by Appellate Medical Board

FORM ‐T Annual Return for the year ending on the 31st December

FORM ‐U Record of Report by Workmen’s Inspector (See Rule 29R and S)



FORM – A (See Rule 48(1))

Notice of Commencement and End of Work

Name of Mine…………….. Owner……………

It is hereby notified that persons employed at this mine shall begin and end their period of work between thee hours set out below.

Sl.No. Class or kind of employment

Sex Place of work

Set or Relay Number A,B,C etc)

1. Set or Relay A B C D

Etc. Above

Ground/ Opencast/ working Below ground

2. Shift 1 2 3 1 2 3 1 2 3 1 2 3 Period of Work 3. Begins AM /PM Ends* AM/ PM *Interval for Rest if any AM/ PM 4. Begins* AM/PM Ends* AM/PM 5. System of Change of

Shifts

1 2 3 4

5

6. Date on which this notice was first exhibited

Signature of Manager……………..

Date ………………… Note: *The words and letters not required shall be scored out.



FORM – B See Rules 48(3), 51, 77 and 77.A(2))

1. (Serial No.

2. Name and surname of the employee

3. Father’s or Husband’s name

4. Age and sex.

5. No. and dates of the certificate, if any, held under the Mines Vocational Training Rules,1966

6.

a) Designation of the employee.

b) Nature of employment (whether above or below ground and if above ground whether in opencast working or otherwise.)

c) Whether employment is permanent or temporary or casual.

7. Home Address of the employee, giving Village, Thana, Post office and District.

8. Date of commencement of employment

9. Date of first appointment, with the present owner.

10. Date of termination or leaving of employment.

11. In case of an adolescent, reference to certificate of fitness granted under section 40.

12. Mark of identification on the body.

13. Name, address, relationship of person to be informed in case of accident/emergency.

14. Token number and other particulars by which the employee may be identified.

15. Passport size photograph of the person employed. PHOTO

16. Signature or Thumb impression of the employee.

17. Remarks.

Signature of Manager



FORM – C (See Rule 48(3) and 78)

Register of Persons Employed Below Ground During the Weak Commencing………and Ending…….20…..

Name of Mine…………………...Part or Section of Mine…………………….. Name of Owner………………………….Hours of Shift Ends………………...

Begins A.M.

‐‐‐‐ P.M.

Begins A.M.

‐‐‐‐ P.M.

Sl.N o.

Name and sur‐name of employ ee

Ag e & Se x

Class or kind of employ ment

Relay or set No.

Serial No. from Form B Regist er

Time should be recorded against each entry Total

Remar ks

Day Day Day Day Day Day Day No.of days worke d

No.of hours worke d

1 2 3 4 5 6 7 8 9 10 11

12 13

14 15

16 17

18 19

20 21 22 23

in out in out in out in out in out in out in out

Initials of Register Keeper

Weekly Abstract Mines including Loaders

[***] Others

Total No. of attendants

Total No. of absentees



FORM – D (See Rule 48(3) and 78)

Register of Persons Employed [Above Ground] in Opencast Working During the

Week Commencing………and Ending…….20…..


Begins A.M.

‐‐‐‐ P.M.

Begins A.M.

‐‐‐‐ P.M.

Sl.N o.


Ag e & Se x

Class or kind of employment

Relay or set No.

Serial No. from Form B Register


Remar ks Day Day Day Day Day Day Day No.of

days worke d

No.of hours worke d

1 2 3 4 5 6 7 8 9 10 11

12 13

14 15

16 17

18 19

20 21 22 23


Initials of Register Keeper

Weekly Abstract Mines including Loaders

*** Others





FORM – E (See Rule 48(3) and 78)

Register of Persons Employed Above Ground [Otherwise Than in Opencast Working] During the Week Commencing………..and Ending ………………20..


Begins A.M.

‐‐‐‐ P.M.

Begins A.M.

‐‐‐‐ P.M.

Sl.N o.


Ag e & Se x

Class or kind of employment

Relay or set No.

Serial No. from Form B Register


Remar ks

Day Day Day Day Day Day Day No.of days worke d

No.of hours worke d

1 2 3 4 5 6 7 8 9 10 11

12 13

14 15

16 17

18 19

20 21 22 23


Initials of Register keeper

Weekly Abstract Mines Women [***]





FORM F (See Rule 49(4))

Name of Mine………………… Owner………………. Year…………………………..

Register of Compensatory Days of Rest.

Sl.No. from Form B Register

Name and surname of employe e

Class or kind of employmen t set or Relay No.

No. of Days of compensator y rest due in the previous calendar year

Dates on which weekly days of rest have not been allowed

Dates on which compensatory days of rest have been allowed

No. of compensator y days of rest due on 31st December

Remark s

1st Jan to 31st M

arch

1st A

pril to 30th June

1st July to 30th Sept

1st O

ct to 31st D

ec

1st Jan to 30th Sept

1st A

pril to 30th June

1st July to 30th Sept

1st O

ct to 31st D

ec

1 2 3 4 5 6 7 8 9 10 11 12 13 14



FORM – G (See Rules 53)

Name of Mine……………….. Owner…………….

Register of Leave Account During the Calendar Year…………..

Serial N

o. from Form B

Register

Nam

e an

d surnam

e of employ

ee

Nature of employ

ment, mentio

ned

whether abo

ve or b

elow groun

d Category of employ

ment,

mentio

n whether m

onthly, w

eekly,

daily or p

iece‐rated

.

Actual Number of days worked during the year Leave period due in ensuing year

Remarks

Janu

ary

Februa

ry

March

April

May

June

July

Aug

ust

Septem

ber

Octob

er

Nov

ember

Decem

ber

Total

Days of leave

entitled

Arrears from

previous year

Total

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ E 1 0

FORM H [See rule 53)

Register of Leave Wages Account During the Calendar Year...........

Name of Mine................................ Owner.............................

Serial N

o. from Form B Register

Nam

e an

d Su

rnam

e of employ

ee

Total leave period du

e in th

e year (F

rom Form G)

Leave Installment

Leave Installment Leave Installment

Calculated da

ily ra

te of w

ages or e

arning

s includ

ing concession

s

Period of leave availed

Calculated leave wages fo

r the period

Leave wages actua

lly paid

Date of payment

Calculated da

ily ra

te of w

ages or e

arning

s includ

ing concession

s


Calculated leave wages fo

r the period

Leave wages actua

lly paid

Date of payment

Calculated da

ily ra

te of w

ages or e

arning

s includ

ing concession

s


Calculated wages fo

r the period

Leave wages actua

lly paid

Date of payment

Period

Amou

nt

Remarks

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Note:—The date of payment of arrears of leave wages shall be entered in the Remarks column.



FORM – I (See Rules 59)

Register of Overtime Wages

Serial N

o. from Form B Register

Nam

e an

d Su

rnam

e of employ

ee

Nature of w

ork abov

e or below

grou

nd

Class or k

ind of employ

ment

Ordinary rate of w

ages

Ovrtim

e rate of w

ages

Week ending Week ending

Date on w

hich overtim

e worked

Num

ber o

f overtim

e ho

urs

worked on th

at date

Num

ber o

f overtim

e ho

urs in

the week

Overtim

e Ea

rning

Date of Payment

Date on w

hich overtim

e worked

Num

ber o

f overtim

e ho

urs

worked on th

at date

Num

ber o

f overtim

e ho

urs in

the week

Overtim

e Ea

rning

Date of Payment

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Week ending Week ending Weekending

Remarks

Date on w

hich overtim

e worked

Num

ber o

f overtim

e ho

urs

worked on th

at date

Num

ber o

f overtim

e ho

urs in

the week

Overtim

e Ea

rning

Date of Payment

Date on w

hich overtim

e worked

Num

ber o

f overtim

e ho

urs

worked on th

at date

Num

ber o

f overtim

e ho

urs in

the week

Overtim

e Ea

rning

Date of Payment

Date on w

hich overtim

e worked

Num

ber o

f overtim

e ho

urs

worked on th

at date

Num

ber o

f overtim

e ho

urs in

the week

Overtim

e Ea

rnings

Date of Payment

17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

Name of Mine…………………… Owner………………… Month …………………..



FORM – J (See Rules 76)

Report of Accident

Register of reportable accidents

S.No.

Date of entry

Date of accident

Time of accident

Classification

Brief d

escriptio

n of case of

accide

nt

Nam

e of in

jured worker

Sl. N

o. from Register in

Form B.

Nature of employ

ment

Nature of in

jury

Parts o

f bod

y injured

Date of re

turn of injured

person to w

ork

Duration of enforced absence

(in days)

Initials of atte

nding Med

ical

practitioner

Remarks

By place of a

ccident

By Cau

se

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Instructions:— Col. (5): Specify as indicated in Annexure I. Col. (6): Specify as indicated in Annexure II. Col. (7): Give brief description of the circumstances attending the accident. Col. (11): Specify whether simple wound, laceration, abrasion or fracture (only toes, fingers and thumb etc.) Col. (14): Mention the days intervening the days of occurrence and day of rejoining and not including either the date of occurrence or rejoining. Col. (16): In case if an injury proves ‘Serious’ or ‘Fatal’ or when injured person proceeds on leave or leaves his employment, particulars should be entered in this column.

Name of Mine…………………… Owner………………… State ………………….. District………………….. Mineral worked………………….. Quarter ending …………………..



ANNUXURE – 1 TO FORM J

Classification of Accident by place of work (Column – 5) 1. Below ground :

1.1. Development face 1.2. Other Development area 1.3. Longwall face 1.4. Other Depillaring/stopping area 1.5. Tramming roadway 1.6. Other rope haulage roadways 1.7. Shafts and sinking shaft (including inclined shafts) 1.8. Inclines and Winze 1.9. Other (Specify)

2. Opencast Workings : 2.1. Bottom Bench 2.2. Top of the Quarry 2.3. Other benches 2.4. Rope Haulage roadway 2.5. Other Transportation roadways 2.6. Other (Specify)

3. Aboveground (Excluding Opencast Workings) : 3.1. Aerial Ropeway –site 3.2. Rope Haulage Roadways 3.3. Other transportation Roadways 3.4. Railway line belonging to the mine 3.5. Site of ore handling plants (including screening plants Dressing Plants, Crushing Plants, etc) 3.6. Workshop, Power‐house and other engine rooms 3.7. Depot 3.8. Other (Specify)

ANNUXRE – II TO FORM J

CLASSIFICATION OF ACCIDENTS by cause (Column 6) 1. 1. Ground movements:

1.1. Fall of roof 1.2. Fall of sides (other than overhang) 1.3. Fall of overhang 1.4. Rock Burst of Bump 1.5. Air Blast 1.6. Premature collapse of workings/pillars 1.7. Subsidence 1.8. Landside 1.9. Collapse of shaft

2. Transportation Machinery (Winding in shaft) 3. Transportation Machinery (other than winding in shaft): 3.1. Aerial Ropeway 3.2. Rope Haulage 3.3. Other Rail Transportation 3.4. Mechanical conveyors 3.5. Dumpers & other heavy earth movers 3.6. Other wheeled trackless means of transportation (Trucks, lorries, etc.)



4. Machinery‐other than Transportation Machinery :

4.1. Drills 4.2. Coal cutting Machinery 4.3. Coal Loading Machinery 4.4. Haulage Engine 4.5. Winding Engine 4.6. Shovels, Draglines, Excavators etc. 4.7. Ore handling Plants (including crushing and screening plants) 4.8. Pumps 4.9. Other (specify)

5. Explosive 6. Electricity 7. Dust Gas and other combustible material : 7.1. Occurrence of gas 7.2. Influx of gas 7.3. Suffocation by gases 7.4. Explosion or ignition of gas/ dust etc. 7.5. Outbreak of fire or spontaneous heating 7.6. Others (Specify)

8. Falls (other than falls of ground) :

8.1. Falls of persons from heights or into depths 8.2. Falls of persons on the same level 8.3. Falls of objects other than falls of ground 8.4. Other falls (Specify)

9. Other Cause : 9.1. Irruption of water 9.2. Flying pieces 9.3. Extremity caught in between objects 9.4. Unclassified (Specify)”}



FORM – K

[See rule 76(2)]

Return of Minor Accidents

Name of the Mine…………………………… Sate ……………………………… District……………………………………… Owner………………………. Mineral worked…………………………. Quarter ending on………………………….

Sl. No. Date of entry

Date of accident

Time of accident

Classification Brief description of place of accident

Name of injured worker

By place of accident

By cause

1 2 3 4 5 6 7 8

1 2 3 4 5 Sl. No. from Register in Form “B”

Nature of employment

Nature of injury

Part of body injured

Date of return of injured person to work

Initials of attending medical practitioner

Remarks

9 10 11 12 13 14 15 1 2 3 4 5 Instructions Col. (5): Specify as indicated in Annexure I to Form J Col. (6): Specify as indicated in Annexure II to Form J Col. (7): Give brief description of circumstances attending the accident Col. (11): Specify whether simple wound, laceration, abrasion etc. Col. (15): In case an injury proves “reportable”, “serious” or “fatal” or when injured person proceeds on leave or leaves his employment, particulars should be entered in this column.



FORM – L (See Rule 54)

Information Regarding Leave With Wages

Name and surname of employee

Serial number from Register in Form “B”

Nature of employment whether below ground or above ground

Actual number of days worked during the preceding year

Days of leave with wages enjoyed during the preceding year

Days of leave to which he is entitled

Arrears of leave carried over from the previous year

Total number of days of leave with wages due

Remarks if any

1 2 3 4 5 6 7 8 9

Signature Designation: Owner/agent/manager Mine : Owner :

Dated ………………………….



FORM ‐ M (See rule 29D (1)}

Notice of Initial/ Periodical Medical Examination Under Rule 29‐B

No………….. Date………………….

Sri/Srimati………………. Nature of employment**……………… Serial number from B Register** son/daughter or/wife *of …………. is hereby notified that he/she* should present himself/herself* for an initial/periodical* medical examination, under Rule 29B of the Mines Rules 1955, before…..(given name of the examining authority) at ……..(give date) at ……..(give time)

Shri/Shrimati*…………. may note that if he/she* fails, without reasonable cause, to submit himself/herself* for the medical examination aforesaid he/she shall not be eligible for appointment/continuance in employment to the mine from………………

Shri/Shrimati*……………. May further note that he/she* should bring with him/her* three unattested photographs of himself/herself* and the previous medical certificates in Form O, if any, issued to him/her* under rule 29 F.

Signature of manager …………………mine

* Delete whatever is not applicable ** Necessary only in case of a person already employed in the mine. *** In respect of the initial medical examination of a person already employed in a mine and in respect of every

periodical medical examination atleast twenty days prior notice is to be given. In respect of the initial medical examination of a person seeking employment at a mine the period of notice may be shorter.

Note – A copy of the notice shall be sent to the examining authority concerned. In the case of periodical medical examination, the copy of medical certificate in Form O shall also be sent.



FORM ‐ N {See rule 29D (S)}

Second and Final Notice of Initial/Periodical Medical Examination Under Rule 29‐B No……… Date………….

Shri/Shrimate*…………… nature of employment………… serial number from Form B Register……… Son/daughter/wife of ………. failed to present himself/herself* for an initial/periodical* medical examination on…… in respect of which he/she/had been given a notice on ………….

He/She* is hereby again notified that he/she* should present himself/herself* for an initial/periodical* medical examination, under rule 29B of the Mines Rules, 1955, before……….(give name of the examining authority) at ……(give date)……..at……….(give time)

Shri/Shrimati*…………, may note that if he/she* fails to submit himself/herself* for the medical examination aforesaid, he/she* shall not be employed/retained in employment in the mine from………

Shri/Shrimati*………….., may further note that he/she* should bring with him/her* three unmounted photographs of himself/herself* and he previous medical certificate in Form O, if any, issued to him/her* under rule 29F.

Signature of Manager

…………………mine * Delete whatever is not applicable ** In respect of the initial medical examination of a person already employed in a mine and in respect of every

periodical medical examination, the second notice is to be given atleast 10 days previously.



FORM – O (See rule 29F (2) and 22L)

Report of Medical Examination Under Rule 29‐B (To be issued in triplicate)**

Certificate No…………..

Certified that Shri/Shrimati* employed as ………. in ………mine, Forrm D No. has been examined for an initial/periodical * medical examination. He/she* appears to be………… years of age. The findings of the examining authority are given in the attached sheet. It is considered that Shri/Shrimati*…………..

a. * is medically fit for any employment in mines. b. * is suffering from…………. And si medically unfit for

i. any employment in mine; or ii. any employment below ground; or iii. any employment or work……….

c. * is suffering from………… is should get this disability* cured/controlled and should be again examined

within a period of ………..months. He/She* will appear for re‐examination with the result of test of………… and the opinion of …………specialist from………… He/She* may be permitted/not* permitted to carry on his duties during this period.

Signature of the examining authority ………………………………………… Name and designation in Block letters

Place :

Date :

* Delete whatever is not applicable. ** One copy of the certificate shall be handed over to the person concerned and another copy shall be sent to the manager of the mine concerned by registered post; and the third copy shall be retained by the examining authority,

Space for affixing Passport Size Photograph of the Candidate



FORM O – Cont. Report of the Examining Authority

(to be filled in for every medical examination whether initial or periodical or reexamination or after cure/control of disability). Annexure to Certificate No…………as result of medical examination on ……. Identification Mark……………..

Left thumb impression of the candidate

1. General development‐ Good/Fair/Poor 2. Height…………Cms. 3. Weight…………kg. 4. Eyes :

i. Visual acuity‐Distant vision (with or without glasses).

Right eye……..Left eye………….. ii. any organic disease of eyes iii. night blindness iv. Colour blindness v. Squint

(* to be tested in special cases)

5. Ears : i. Hearing : right ear………….Left ear …………….. ii. Any organic diseases.

6. Respiratory system.

Chest measurement : i. after full inspiration …………cms. ii. After full expiration…………..cms.

7. Circulatory system:

Blood Pressure Pulse

8. Abdomen : Tenderness. Liver. Spleen. Tumour.

9. Nervous system: History of fits or epilepsy Paralysis. Mental helath.

10. Locomotory system 11. Skin. 12. Hyrocele.



13. Hernia. 14. Any other abnormality 15. Unine :

Reaction. Albumin. Sugar.

16. Skiagram of chest. 17. Any other ‘ c ‘ test considered necessary by the examining authority. 18. Any opinion of specialist considered necessary.

Signature of the examining authority

Place:



FORM – P (See rule 29F (i) and 29L)

Medical Standard of Fitness for Persons Employed

1. The person should be in good mental and bodily health and free from any physical defect likely to interfere with his efficient employment in a mine.

2. Skeletal nervous system : The limbs should be well formed and developed, and the function of all the limbs should be within normal limits. Any deformity should be recorded. There should be no deformity or paralysis which may interfere with his efficient employment in a mine.

3. Skin :There should be no evidence of extensive and chornic skin disease or ulceration. In case of infective type of skin disease, the candidate could be made fit after he has undergone a treatment. All occupational skin diseases should be noted.

4. Eye vision should be not less than the following standard: 1) Better eye 6/12 2) Worse eye 6/18 b. There should be no night blindness for persons employed below ground and for persons employed

in open cast working in shifts other than in mornings shifts. c. A person having only one eye which functions normally should not be employed below ground,

For employment on surface the vision of such a person in the other eye should be 6/18 with or without glasses.

5. Hearing should be good. Any progressive disease affecting hearing/or occupational deafness should be

recorded. 6. Speech must be without serious impediment. Unless this is also accompanied by generalised partial

paralysis this should not be a reason for declaring unfit. 7. (a) Respiratory system should be sound and free from any chronic bronchial or laryngeal disease. This

however alone should not be reason to make unfit. (b) A full sized postero‐anterior chest radiograph (large enough to include thoracic inlet and both costophrenic angles) obtained by an X‐ray machine of at least 300 mA (A Milli‐Ampere) strength shall be evaluated in the manner specified by the Chief Inspector and Lung function tests (spirometry) to record forced vital capacity (FVC) and forced expiratory volume in one second (EFVI) shall be made. There should not be any evidence of active pulmonary disease. If there are evidences of active pulmonary tuberculosis he may be permitted to work if his sputum is negative on repeated examination and on production of a certificate that he is taking treatment from a qualified medical practitioner/ Hospital.

8. Circulatory system – There should be no evidence of any heart or vascular disease which may interfere with his efficient employment in a mine.

9. In case the candidate has hernia he may be declared fit after he has been successfully operated for the same. 10. Hydrocele if present should not be large enough to impede the normal activities of the candidate. In such

cases he may be declared fit after being successfully operated. 11. The medical examination should include examination of urine and of other system for evidence of disease.

Mere presence of albumen and sugar in the urine without any gross organic disease producing signs and symptoms should not be considered as a disability.



FORM P‐I

(See rule 29F(1) and 29L)

Medical Standard of Fitness for Persons to be Employed in Mines. 1. The person should be in good mental and bodily health and free from any physical defect likely to interfere with

his efficient employment in a mine. Due allowance in the standard should be made for the age of a candidate. 2. Locomotor system – The limbs should be well formed and developed and the function of all the limbs should be

within normal limits. Any deformity should be recorded. There should be no deformity or paralysis which may interfere with his efficient employment in a mine. Any deformity noted should be recorded.

3. Skin – There should be no evidence of extensive and chronic skin disease or ulceration. 4.

a. Distant vision eye with or without glasses should be not less than the following standard.

For workers employed on surface and in opencast workings

For workers employed below ground

1. Better eye……………….. 2. Worse eye

6/12 6/18

6/6 6/9

b. Night blindness should be tested in special cases only in underground workers where the examining

authority considers it necessary. c. A person having only one eye which functions normally should not be employed belowground. For

employment on surface the vision of such a person in the other eye should be 6/12 with or without glasses. A person will be considered uniocular when there is physical loss of one eye or when there in functional loss of vision of one eye.

d. Colour blindness will be tested only in special cases where the job requires good colour discrimination. Only low grade colour perceptions will be tested with Edridge Green’s lantern.

e. There should not be squint where binocular vision is essential. f. There should not be any organic disease of the eye which is likely to affect the distant vision within a

period of five years. 5. Hearing should be good. Any progressive disease effecting hearing should be recorded. The candidate should be

able to hear conversational voice from a distance of 3 metres. 6. Speech must be without serious impediments. 7.

(a) Respiratory system should be sound and free from any chronic laryngeal bronchial pulmonary disease. Tuberculosis of lungs if not active should not be a disqualification.

(b) A full sized postero‐anterior chest radiograph (large enough to include thoracic inlet and both costophrenic angles) obtained by an X‐ray machine of at least 300 mA (A Milli‐Ampere) strength shall be evaluated in the manner specified by the Chief Inspector and Lung function tests (spirometry) to record forced vital capacity (FVC) and forced expiratory volume in one second (EFVI) should be made and there should not be any evidence of active pulmonary disease.

8. Circulatory system – There should be no evidence of any heart or vascular disease which may interfere with his efficient employment in a mine.

9. There should not be any evidence of disease of abdominal organs which is likely to affect his efficient discharge of duty in a mine.

10. In case the candidate has hernia, he may be declared fit after he has been successfully operated for the same. 11. Hydrocele if present should not be large enough to impede the normal activities of the person. If it is large

enough he may be declared fit after being successfully operated. 12. The nervous system should be sound. Persons with history of epilepsy or any other type of organic or historical



fits should not be declared fit for employment in a mine. 13. The medical examination should include examination of urine. Mere presence of albumen and sugar in the

urine without any gross organic disease producing signs and symptoms should not be a disability. 14. Skiagram of the chest should also he obtained. If it is necessary, the medical officer may direct the candidate to

obtain the result of special tests or/and the opinion of a specialist from recognized institution/hospital.



FORM – Q

(See rule 29J(2) 9 (a))

Notice of Medical Re‐Examination by Appellate Medical Board

No……….. Date………………..

MEMORANDUM

Shri/Shrimati*………..Nature of employment……………serial number from From B Register………… son/daughter/wife* of ………….., who has appealed for a re‐examination against the findings of a medical examination under rule 29B of Mines Rules, 1955 that he/she is unfit for :

a. *Any employment in mines. b. *Any employment below………. Ground. c. *Any employment on work………..(Specify in detail) is hereby notified that he/she * should present

himself/herself* for a medical reexamination by the Appellate Medical Board at ………. (give exact description of place) on**………….(give date) at ……….(Give time).

Shri/Shrimati*…….may note that if he/she* fails without reasonable cause, to submit himself/herself* for the medical re‐examination aforesaid he/she* shall not be retained in employment in the mine.

Signature of manager ……………………mine.

* Delete whatever is not applicable **15 days, prior notice is to be given to a medical re‐examination by the Appellate Medical Board.



FORM – R (See rule 29J(2) (b) )

Second and Final Notice of Medical Re‐Examination by Appellate Medical Board

No………….. Date……………19

MEMORANDUM

Shri/Shrimati*………..Nature of employment……………serial number from From B Register………… son/daughter/wife* of ………….., failed to present himself/herself* for medical re‐examination on …..in respect of which he/she* had been given a notice on …………

He/She* is hereby again notified that he/she* should present himself/herself* for a medical re‐examination by the Appellate Medical Board at ……..(give exact description of place) on **………….(give date) at …………(give time).

Shri/Shrimati*…..may note that if he/she* fails to submit himself/herself* for the medical re‐examination aforesaid, he/she* shall not be retained in employment in the mine.

Signature of Manager ……………….. mine.

* Delete whatever is not applicable **15 days, prior notice is to be given to a medical re‐xamination by the Appellate Medical Board.



FORM – S (See rule 29L)

Report of Medical Re‐Examination by Appellate Medical Board

(To be issued in triplicate)**

We do hereby certify that we have examined Shri/Shrimati* ……….. Nature of employment…….., Serial Number from Forrm B Register………….. of ….. mine, who has been declared medically unfit for.

a. *any employment in mine. b. *any employment belowground. c. *any employment in work……………………………………. (Specify in details) as a result of a medical

examination under rule 29B. Our Report is given overleaf. We consider that –

1. He/She* is medically fit for any employment in mine. 2. He/She* is suffering from……….. and is medically unfit for

a. *any employment in mine. b. *any employment belowground. c. * any employment in work………. …………………..(Specify in details)

3. He/She is suffering from…………and should get this disability/cured/controlled* and should be again

examined within a period of ……………months. He will appear for re‐examination within a period of…………months. He will appear for reexamination with the result of test of………* and opinion of ………specialist from…………He may be permitted/not permitted* to carry on his duties during this period.

Signature of members of Appellate Medical Board

Place............. Date..............

1…………………(Convenor) 2………….. 3……………

* Delete whatever is not applicable **One copy of certificate shall be handed over to the person concerned and another copy shall be sent to the manager of the mines concerned by registered post, and the third copy shall be retained by the Convener of the Appellate Medical Board.



REPORT OF THE APPLELLATE MEDICAL BOARD

Annexure to certificate No………….as a result of Medical examination On…………….

identification mark :

Left thumb impression of the candidate

1. General development. Good/Fair/Poor 2. Height……….cms. 3. Weigth……….kg. 4. Eyes………

i. visual acuity Distant vision(with or without glasses) ii. any organic disease of eyes. iii. *night blindness Right eye………Left eye…………. iv. *Colour blindness……… v. Squint…………………..

(* to be tested in special cases) 5. Ears :

(i) Hearing……… Right Ear………………… Left Ear……………………. (ii) any organic disease

6. Respiratory system :

Chest measurement i. after full inspiration …….cms ii. after full expiration……

7. Circulatory system :

Blood pressure…………. Pulse…………..

8. Abdomen :

Tenderness…….. Liver…….. Spleen………… Tumour………..

9. Nervous system : History of fits or epilepsy….. Paralysis…….. Mental helath………

10. Locomotor system : 11. Skin : 12. Hernia : 13. Hydrocele :

14. Any other abnormality :

Urine: Reaction…….. Albumin………



Sugar……….. 15. Skiagram of chest : 16. Any other test considered necessary by the examining authority. 17. Any opinion of specialist considered necessary. Place : Signature of the Appellate Medical Board



FORM – T (See rule 29‐P(i))

Annual Return for the Year Ending on The 31st December

1. Name of mines……………… 2. Postal address of Mines…………… 3. Date of opening ……………….. 4. Date of closing (if closed)…………. 5. Situation of Mine (District/State)………….. 6. Name of Owner………..

Postal address of owner………… 7. Number of persons required to be medically examined……….

8. Number of persons medically examined…………… 9. Number of persons declared medically unfit………… 10. Categorization of the persons declared unfit…………. Certified that the information given above is correct to the best of my knowledge.

Signature…………….. Designation…………….. Date………………



FORM – U (See rule 29‐R and 29‐ S)

Record of Report by Workmen Inspector

Name of Mine………Owner…………

Manager…………….. Place/installation Inspected by ………………on ……………

Accompanied by………………

Observations Remedial Measures Suggested

Action taken for remedial measures

Date on which action taken

Remarks if any

Signature of Workmen’s Inspector with date Signature of Manager with date

Signature of mine official Accompanying the work‐Men’s Signature of Manager with date Inspector Date…….. Designation

Forms under

DANGEROUS MACHINES (REGULATION) RULES, 2007

C o m p i l e d b y P o w e r H R F o r u m P a g e - F 1

Forms under

DANGEROUS MACHINES

(REGULATION) RULES, 2007

Forms under



Index FORM I

Form of Licence For Manufacture or Commencement of Carrying on Business as a Manufacturer of a Dangerous Machine

FORM II

Form of Licence for Commencement or Carrying on Business as a Dealer of a Dangerous Machine

Forms under



FORM I [See Rule 3(1) and (3)]

Form of Licence for Manufacture or Commencement of Carrying on Business as a Manufacturer of a Dangerous Machine

Licence No. ..........................

Whereas M/s .............................. .............................. ......................................... .............................. of ........................................................................................................................................................ has/have (give full address) .................... applied for a licence for commencement of/carrying on business as a manufacturer of ..............................................................................

(here specify which dangerous machine)

And whereas the Controller is satisfied that the condition specified in clause (a) of sub section (4) of Section 9 or, as the case may be, sub section (4) of section 9 has been complied with.

Now, therefore, in exercise of the powers, conferred by Section 9 of the Act, licence is granted/renewed to M/s ................................ for a period of five years to commence/carry on business as a manufacturer of the: 1. 2. 3. (give name of machine [ power thresher, power operated chaff cutter, power operated sugarcane crusher ] and trade name with brief description and overall dimensions) This licence is issued subject to the following conditions, namely:— 1. The manufacturer shall ensure that the machine and every part thereof complies with the

standards specified by Rule 4 of the Dangerous Machines (Regulation) (Ammendment) Rules, 2007.

2. Without prejudice to the generality of condition No. (1) above, the manufacturer shall ensure

that the following parts are secured by safeguard of substantial construction :—

(a) The prime mover and every part thereof. (b) The transmission machinery and every part thereof. (c) Every other dangerous part such as rollers, blowers, elevators and the like.

Forms under



3. The manufacturer shall clearly and legibly provide the machine with danger signals indicating the point beyond which no limb shall be inserted for the purpose of feeding the machine or for any other purpose while the machine is in operation.

4. The manufacturer shall ensure that the following particulars are legibly and conspicuously

marked or inscribed on every dangerous machine by such method as would make it indelible, namely :—

a. the direction of the rotation and the number of rotations per minute ;

b. its power requirements; and

c. the name and correct address of the manufacturer, the year of manufacture and the date,

number and other particulars of the licence of the manufacturer. 5. Every manufacturer shall supply along with each dangerous machine a manual containing

general instructions regarding the operation of such machine, and shall also include therein such cautions as may be prescribed.

6. Before transferring the possession of the machine whether by sale, lease, hire or otherwise, the

manufacturer shall deliver to the person acquiring the machine a declaration to the effect that the machine conforms to the standards laid down by or under this Act and also complies, in all respects, with the provisions of the Act and the rules and orders made there under.

7. Failure to comply with the conditions specified above or of any provision of the Act or rule or

order made thereunder will make this licence liable to suspension/cancellation as provided in Section 10.

[N.B.—All references to the Act or any section thereof are references to the Dangerous Machines (Regulation) Act, 1983 (35 of 1983) or the relevant section thereof.] Granted this ................................................... day of. …………................................................. Place .............. Designation Date. .............. (Seal)

Forms under




Form of Licence for Commencement or Carrying on Business as a Dealer of a Dangerous Machine

Licence No ....................... Whereas M/s ........................................................... of .......................................................................

(here give full address) has/have applied for a licence for commencement of/carrying on business as a dealer of ................ ……………………………………………

(here specify which dangerous machine)

And whereas the Controller is satisfied that the applicant proposes to commence/carry on business in ................................................................. which conform to the standards laid down (specify which machine) by or under the Dangerous Machines (Regulation) Act, 1983 (35 of 1983). Now, therefore, in exercise of the powers conferred by sub‐section (4) of Section 9, licence is granted to M/s .................................. for a period of five years to commence/carry on business as a dealer of : Sl. No. Name of the machine Make/model and brief

description HP/KW requirement of

the machine 1. 2. 3.

(specify types of threshers, power operated chaff cutter and power operated sugar cane crusher or other dangerous machine) This licence is issued subject to the following conditions, namely :—

1. The dealer shall deal only in machines of a manufacturer licenced under the Act.

2. Before transferring the possession of any machine whether by sale, lease, hire or otherwise, the dealer shall deliver to the person acquiring the possession of such machine, a declaration to the effect that the machine conforms to the standards laid down by or under this Act and also complies with, in all respects, the provisions of this Act and the rules and orders made there under.

3. Failure to comply with the conditions specified above or any provisions of the Act or rule or oreder made there under will make this licence liable to suspension /cancellation as provided in Section 10.

[N.B.— All references to the Act or any section thereof are references to the Dangerous Machines

(Regulation) Act, 1983 (35 of 1983) or to the relevant section thereof.] Granted this ...................................................... day of ...................................................................... Date ........................ Designation Place ........................ (Seal)

Forms under

ENVIRONMENT (PROTECTION) RULES, 1986

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ G 1

Forms under


Forms under



INDEX

FORM I

Notice of Intention to Have Sample Analyzed

FORM II

Memorandum to Government Analyst

FORM III

Report by Government Analyst

FORM IV Form of Notice

FORM V Environmental Statement for The Financial Year

Forms under



FORM I (See Rule 7)

Notice of Intention to have Sample Analysed To

.......................... ..........................

Take notice that is intended to have analysed the sample of............................................. which has been taken today, the.................................................................. day of......................................20......................................... from*..................................................................................... (Name and designation of the person who takes the sample) ................................................................................................................................................

(SEAL)

DATE...................... *Specify the place from where the sample is taken.

Forms under



FORM II (See Rule 8)

Memorandum to Government Analyst From ........................................ ........................................

To

The Government Analyst

........................................

........................................

The portion of sample described below is sent herewith for analysis (under Rule 6 of the Environment (Protection) Rules, 1986.

The portion of the sample has been marked by me with the following mark:

Details of the portion of samples taken.

Name and designation of person who sends the sample.

(SEAL) Date......................

Forms under



FORM III (See Rule 8)

Report by Government Analyst Report No...................... Date.................................

I hereby certify that I.................................................Government Analyst duly appointed under section 13 of the Environment (Protection) Act, 1986, received on the ................................. day of .................................................................................................................20.........................................................................from......................*...................................................................................................................................................................... a sample of.............................................................for analysis.

The sample was in a condition fit for analysis as reported below.

I further certify that I have analyzed the aforementioned sample on....................... and declare that the result of the analysis to be as follows:

**...........................................................................................................................................................................................................

The condition of seals, fastening of samples on receipt was as follows:

Signed this..................................... day of.......................................20.........................

Address.....................................................................

Signature

(Government Analyst) To

........................................

........................................ ........................................

*Here write the names of the officer/authority from whom the sample was obtained.

** Here write full details of analysis and method of analysis.

Forms under



FORM IV (See Rule 11) Form of Notice

By registered post‐acknowledgement due

From

Shri.................................

........................................

........................................

To

........................................

........................................

Notice under section 19(b) of the Environment (Protection) Act, 1986.

Whereas an offence under the Environment (Protection) Act, 1986, has been committed/is being committed by ..............................(2) I/We hereby give notice of 60 days under section 19(b) of Environment (Protection) Act, 1986, of my/our intention to file a complaint in the Court against ................................. (2) for violation of section.......................................of the Environment (Protection) Act, 1986.

In support of my/our notice, I am/we are enclosing the following documents (3) as evidence of proof of violation of the Environment (Protection) Act, 1986.

Place........................................ Signature(s)

Date........................................

Forms under



FORM V (See Rule 14)

Environmental Statement for the Financial Year Ending the 31st March................ PART A

i. Name and address of the owner/occupier of the industry operation or process.

ii. Industry category Primary—(STC Code) Secondary—(STC Code).

iii. Production capacity‐Units—

iv. Year of establishment.

v. Date of the last environmental statement submitted.

PART B

Water and Raw Material Consumption 1) Water consumption m3/d

Process Cooling Domestic

Name of products Process water consumption per unit of product output

During the previous financial year During the current financial year

(1) (2)

(1) (2) (3)

(2) Raw material consumption *Name of Raw Materials Name of

products Consumption of Raw Materials per unit

During the previous financial year

During the current financial year

*Industry may use codes if disclosing details of raw material would violate contractual obligations, otherwise all industries have to name the raw materials used.

PART C Pollution discharged to environment/unit of output.

(Parameter as specified in the consent issued) Pollutants Quantity of pollutants

discharged (mass/day)

Concentrations of pollutants in discharges

(mass/ volume)

Percentage of variation from prescribed standards with reasons

(a) Water

(b) Air

Forms under



PART D

Hazardous Wastes

(as specified under Hazardous Wastes (Management and Handling) Rules, 1989)

Hazardous Wastes Total Quantity (Kg)



(a) From process (b) From pollution control facilities

PART E

Solid Wastes

Total Quantity



(a) From process (b) From pollution control facility (c) 1. Quantity recycled or re‐utilized within the unit 2. Sold 3. Disposed

PART F

Please specify the characterization (in terms of composition and quantum) of hazardous as well as solid wastes and indicate disposal practice adopted for both these categories of wastes.

PART G

Impact of the pollution abatement measures taken on conservation of natural resources and on the cost of production.

PART H

Additional measures/investment proposal for environmental protection abatement of pollution, prevention of pollution.

PART I

Any other particulars for improving the quality of the environment.

—————

Forms under

DELHI FACTORY RULES, 1950

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ H 1

Forms under the


Forms under



INDEX

FORM 1

Application for Permission to Construct, Extend or take into Use any Building as a Factory

FORM 2 Application for Registration and Grant or Renewal of License for The Year and Notice of Occupation Specified in Sections 6 & 7

FORM 3 Notice of Change of Manager FORM 4

Licence to Work a Factory

FORMS 5 Certificate of Fitness Under Section 107 FORM 6 Humidity Register Under Rule 22 FORM. 7 Record of Lime Washing, Painting etc. Under Rule 16 FORM 7B Report of Examination of Hoist or Lift/ Occupier/ (or Owner) of

Premises Under Rule 55 FORM 8 Report of Examination of Pressure Vessel Under Rule 56 FORM 8A Report of Examination of Water‐Sealed Gasholder Under Rule 56a FORM 9 Register of Compensatory Holidays Under Rule 77 FORM 10 Overtime Muster Roll of Exempted Workers Under Rule 78 FORM 10(A) Overtime Slip for overtime Work Under Rule 78a FORM 11(A) Notice of Periods of Work for Adults Under Rule 79 FORM 11(B) Notice of Periods of Work for Adult Workers Under Rule 76 FORM 12 Register of Adult Workers Under Rule 80 FORM 13 Notice of Periods of Work for Child Workers Under Rule 85 FORM 14 Notice of Periods of Work for Child Workers Under Rule 86 FORM 15 Register of Leave With Wages Under Rule 87 & 88 FORM 16 Leave Book Under Rule 87 & 88 FORM 17 Health Register Under Rule 14 FORM 17A Test Report Of Dust Extraction System Under Rule 56a FORM 18

Notice of Accident or Dangerous Occurrence Resulting in Death or Bodily Injury Under Rule 96

Forms under



FORM 18A

Notice of Dangerous Occurrence Which Does Not Result in Death or Bodily Injury Under Rule 96

FORM 19

Notice of Poisoning or Disease

FORM 20 Abstract of Factories Act, 1948 and The Delhi Factories Rules, 1950 to be Fixed in a Conspicuous and Convenient Place at or Near the Main Entrance to the Factory

FORM 21 (NOW FORM NO.34)

Annual Return Under Rule 100

FORM 22 Half‐ Yearly Return Under Rule 100 FORM 23 Deleted Vide Notification No. F .11 (16)/58‐ I &L Dated 26‐11‐60 and

Included For No.2) Form No. 22 FORM.24 Annual Return (Creche) Under Rule 100 FORM 25 Deleted Vide Notification No. F.11 (16)/58‐ I & L Dated 26‐11‐60 and

Included in Form No.21 FORM 26 Muster Roll Under Rule 103 FORM 27 Register of Accidents and Dangerous Occurrences Under Rule 104 FORM 28

Special Certificate of Fitness (In Respect of Persons Employed in Operations Involving Use of Lead Compounds) Under Rule 95

FORM 29 Under Rule 53 A

Forms under



FORM NO. 1 (Prescribed under Rule 3)

Application for Permission to Construct, Extend or Take Into Use any Building as a Factory

1. Applicantʹs Name.....................................................................

Applicantʹs Calling.....................................................................

Applicantʹs Address.....................................................................

2. Full Name & Postal address of factory.....................................................................

3. Situation of the factory‐.....................................................................

Province.....................................................................

District.....................................................................

Town or village.....................................................................

Nearest Police Station.....................................................................

Nearest Railway Station or Steamer Ghat.....................................................................

4. Particulars of plant to be installed.....................................................................

Signature of Applicant

Date.....................................................................

NOTE:‐ This application shall be accompanied by the following documents:

a. A flow chart of the manufacturing process supplemented by a brief description of the process in its various stages;

b. Plans, in duplicate, drawn to scale, showing :‐

i. the site of the factory and immediate surroundings including adjacent buildings and other structures, roads, drains etc. and

ii. the plan elevation and necessary cross‐sections of the various buildings, indicating all relevant details relating to natural lighting, ventilation and means of escape in case of fire. The plans shall also clearly indicate the position of the plant and machinery aisles and passage ways; and

c. Such other particulars as the Chief Inspector may require.

Forms under




Application for Registration and Grant or Renewal of License for the Year and Notice of Occupation

Specified in Sections 6 & 7

1. Full name of the factory with factory licence No. if .......... already registered. 2.

a. Full Postal address and situation of the factory. ............ b. Full address to which communication relating to ................the factory should be sent.

3. Nature of manufacturing process/processes.

a. Carried on in the factory during the Last twelve months………………… (in the case of factories already in existence)

b. to be carried on in the factories during the next twelve months……………… (in the case of all factories)

4. Names and values of principal products manufactured during the last 12 months. 5.

i. Maximum number of workers proposed to be employed on anyone day during the year. ii. Maximum number of workers employed on any one day during the last 12 months. iii. Number of workers to be ordinarily employed in the factory.

6. i. Nature and total amount of power (H.P. installed or proposed to be installed). ii. Maximum amount of power (H.P.) proposed to be used.

7. Full name and residential address of the person who shall be the Manager of the factory for the purposes of the

Act. 8. Full name and residential address of the occupier:

i. The Proprietor of the factory in case of private firm/proprietory concern. ii. Directors in case of a public limited liability company/firm. iii. Where a Managing Agent has been appointed the name of Managing agents and Directors thereof. iv. Shareholders in case of a private company where no Managing Agent has been appointed. v. The Chief Administrative Head in case of a Government or local fund factory.

9. Full name and address of the owner of the premises or building (including the precincts thereof) referred to in

Section 93. 10. In case of factory constructed or extended after the date of the commencement of the Delhi Factories Rules, 1950.

a. Reference number and date of approval of the plans or construction or extension of factory by the Chief Commissioner /Chief Inspector.

b. Reference number and date of approval of the arrangements, if any made for the disposal of trade waste and effluents and the name of the authority granting such approval.

Forms under



11. Amount of fee Rs........ (Rupees) ....... paid in ........Treasury on ........vide challan No ........ (enclosed

Signature of Occupier……… Date…………………………

Signature of Manager………..

Date………………………… Notes: 1. This form should be completed in ink in block letters or typed.

2. If power is not used at the time of filling up this form; but is introduced later; the fact should be communicated to the Chief Inspector immediately.

3. If any of the person named against item 8 is minor, the fact should be clearly stated.

4. In the case of a factory, where under the provision of sub‐sections 1 and 2 of Section 100, a person has been nominated as the occupier, information required in item 8 should be supplied only in respect of that person.

5. In the case of a factory where a managing Agent or Agents have been appointed as occupiers under the Indian Companies Act, 1913 VII of 1913), information required in item 8 should be supplied on y in respect of that person or persons.

Forms under



FORM NO. 3 (Prescribed under Rule 12A)

Notice of Change of Manager

1. Name of factory with current license number....................................................................

2. Postal address....................................................................

3. Name of outgoing manager....................................................................

4. Name of new manager with postal address of his residence and telephone number, if installed....................................................................

5. Date of appointment of the new manager with parentage....................................................................]

Date Signature of new Manager Signature of Occupier Place

Forms under



FORM NO. 4 (Prescribed under Rule 5) Licence to Work a Factory

Licence No............................... Reg. No............................... Date of Reg........................... Licence is hereby granted to..................................................... for premises known as .................................................. situated at.............................................. for use as a factory within the limits stated hereinafter, subject to provisions of the Factoryʹs Act, 1948, and the rules made there under :‐

The.................. 20 Issuing Authority

Valid for

Calendar Year

Maximum number of workers on any day

Maximum installed power capacity in

Fee Date of payment

Excess fee of late payment

Date of payment

signature of the Issuing Authority

Granted under Rule 5

Renewed under Rule 7

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………………………………………..

TRANSFERS

To whom transferred Year of transfer Date of payment of transfer fee Signature of the Issuing Authority

Forms under



AMENDMENTS

Year When amended

Workers Installed power capacity in H.P

Date of payment of amendment fee

Additional fee Date of fee Signature of the issuing Authority

Forms under


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ H 1 0

FORM NO. 5 Rule prescribed under Section 107

Certificate of Fitness 1. Serial No...............................................................

Date………………………………………………

2. Name ...................................................................

3. Fatherʹs Name .....................................................

4. Sex .......................................................................

5. Residence ............................................................

6. *Date of Birth, if available and / or age Certified

............................................................................

7. Physical Fitness ......................................................

8. Descriptive marks ...............................................

................................................................................

................................................................................

................................................................................

9. Reason for –

1. Refusal of certificate .......................................

…………………………………………………..

2. Certificate being revoked ...............or............

................................................................................

................................................................................

................................................................................

Initials of Certifying Surgeon Certifying Surgeon

Note;‐ Exact details of cause of physical disability should be clearly stated.

* Vide Notification No. F.1(135)/53‐I & L (ii) dated 25 th June, 1957 .

Serial No.........................................................

Date……………………………………………………………

I hereby certify that I have personally examined Name................................................

.........................................................................

.........................................................................

Son/ Daughter ........................................................

.........................................................................

.........................................................................

who is desirous of being employed in a factory, and that his / her age, as nearly as can be as certained from my examination, is .................. years; and that he/ she is fit for employment in factory as an adult / child.

His / her descriptive marks are ...............................

.........................................................................

.........................................................................

Thumb impression Thumb impression

Forms under



FORM NO. 6 (Prescribed under Rule 22) Humidity Register

Department ......................................................................

Hygrometer Distinctive mark or number ...............................................

Position in department......................................................

Readings of Hygrometer

Between 7 and 9 a.m. Between 11a.m. and 2p.m. (but not in the rest period)

Between 4 and 5.30 p.m.

If on humidity insert none

Remarks

Date Year Month Day Dry Bulb

Wet Bulb Dry Bulb Wet Bulb Dry Bulb Wet Bulb

1st ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

2nd ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

3rd ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

4th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

5th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

6th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

7th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

8th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

9th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

10th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

11th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

12th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

13th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

14th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

15th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

16th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

17th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

18th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

19th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

Forms under



20th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

21st ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

22nd ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

23rd ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

24th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

25th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

26th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

27th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

28th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

29th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

30th ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

31st ‐‐‐‐ ‐‐‐‐‐‐ ‐‐‐‐

(Signed) .....................................................

Certified that the above entries are correct

(signed) ....................................................

Forms under




Record of Lime washing, Painting etc.

Part of factory e.g. name of room

Parts lime‐washed, painted, varnished or oiled e.g. walls, ceiling, wood work etc.

Treatment, whether lime‐washed, painted varnished or oiled

Date on which lime‐washing, painting varnishing or oiling was carried out (according to the English calendar)

Remarks

Date Month Year

1 2 3 4 5 6 7

Forms under



FORM NO. 7B (Prescribed under Rule 55)

Prescribed for Report of Examination of Hoist or Lift/ Occupier/ (or owner) of Premises

Address:

1.

a. Type of hoist or lift and Identification number or description.

b. Date of construction or re‐construction (if ascertainable).

2. Design and construction.

Are all parts of the hoist or life of good mechanical construction sound material and adequate strength (so as ascertainable).

3. Maintenance.

Are the following parts of the hoist or lift properly maintained and in good working order, If not, state what defects have been found :‐

a. Enclosure of hoistway or liftway. b. Landing gates and cage gate(s). c. Interlocks on the landing gates and cage gate(s). d. Other gates fastenings. e. Cage and platform and fittings guides, buffers, interior of the hoistway or liftway. f. Over‐running devices. g. Suspension ropes or chain and their attachments. h. Safety gear, i.e. arrangements for preventing fall of platform or cage brakes. i. Brakes. j. Worm or super gearing. k. Other electrical equipment. l. Other parts.

4. What parts (if any were) inaccessible.

5. Repairs, renewals or alterations (if any) required and the period with which they should be executed.

6. Maximum safe working load subject to repairs, renewals or alterations (if any) specified in (5).

7. Others.

I/We verify that on .......................I/We thoroughly examined this hoist of life and that above is correct report of the result.

Signature............. Counter signature...........

If employed by a company or association give names and address.

Qualification ........................................................... Address.................................................................. Date ................................

Date .............................

Note:‐Details of any renewal or alterations required should be given in 5 above.

Forms under




Report of Examination of Pressure Vessel

Address:

1. Name of Occupier (or Factory…………………………………………………………….

2. Situation and address of Factory…………………………………………………………….

3. Name, description and distinctive number of pressure vessel…………………………………

4. Name and address of manufacturers…………………………………

5. Nature of process in which it is used…………………………………

6. Particulars of vessel :‐

a. Date of construction…………………………………

b. Thickness of walls…………………………………

c. Date on which the vessel was first taken into use…………………………………

d. Safe working pressure recommended by the manufacturer…………………………………

e. The history should be briefly given, and the examiner should state whether he has been the last previous report…………………………………

7. Date of last hydraulic test (if any) and pressure applied…………………………………

8. Is the vessel in open, or otherwise exposed to whether or to damp …………………………………

9. What parts (if any where in accessible) …………………………………

10. What examination and tests were made? (specify pressure if hydraulic test was carried out.)………..

11. Condition of vessel (State any defects materially affecting the safe working pressure or the safe working of the vessel). …………………………………

External...........

Internal............

12. Are the required fittings and appliance provided in accordance with the rules of pressure vessels ?..........

13. Are all fitting and appliance properly maintained and in good condition ? …………………………………

14. Repairs (if any) required, and period within which they should be executed and any other condition which the person making the examination thinks it necessary to specify for accuring safe working……………….

15. Safe working pressure, calculated from dimensions and from the thickness, and other data ascertained by the present examination, due allowance being made for conditions of working if unusual or exceptionally severe (State minimum thickness of walls measure during the examination)………………………….

16. Where repairs affecting the safe working pressure are required, state the working pressure

a. Before the expiration of the period specified in (14) …………………………………

b. After the expiration of such period if the required repairs have not been completed……………

c. After the completion of the required repairs ....................

Forms under



17. Other observations.............................

I certify that on ...................... the pressure vessel described above was thoroughly cleaned and (so far as its construction permits) made accessible for thorough examination and for such tests as were necessary for thorough examination and that on the said date, I thoroughly examined this pressure vessel including its fittings, and that the above is a true report of my examination.

Signature ....................

Qualification ..................

Address ......................

Date ........................

If employed by a Company or Association................................................ give name and address.

Forms under



FORM NO. 8A (Prescribed under Rule 56A)

Report of Examination of Water‐Sealed Gasholder 1. Name of Occupier of Factory

2. Situation and address of Factory

3. Name, description, distinguishing number or letter and type of gasholder.

4. Name and address of the manufacturer.

5.

a. No. of lifts.

b. Maximum capacity in cub‐meters (cub. ft.)

c. Pressure thrown by holder when full of gas.

6. Particulars of gas to be stored in the holder.

7. Particulars as to be condition of‐

a. Crown

b. Side sheeting, including grips and cups.

c. Guiding Mechanism (Roller carriages, rollers, pins, guide rails or ropes.).

d. Tank.

e. Other structure, if any (columns, framing and bracing).

8. Particulars as to position of the lifts at the time of examination.

9. Particulars as to whether the tank and lifts were found sufficiently level for safe working and if not, as to the steps taken to remedy the defect.

10. Date of examination and by whom it was carried out.

11. Condition of vessel

1. External

2. Internal

12. Are all fittings, appliances properly maintained and in a good condition, repairs, if any, required and period within which they should be executed and any other condition which the person making the examination thinks it necessary for safe working.

13. Other observations.

I certify that on…………………the gasholder described above was thoroughly examined and such of the tests as were necessary made on the same day and that the above is a true report of my examination.

Signature ....................

Qualification ..................

Address ......................

Date ........................

If employed by a Company or Association................................................ give name and address.

Forms under




Register of Compensatory Holidays Serial

Number Number in the register

of workers

Name Group of Relay No.

Number & Date

Exempting order

Year Weekly rest days lost due to the exempting order in

January to

March

April to June

July to September

October to December

1 2 3 4 5 6 7 8 9 10

Date of compensatory holidays given in Last rest days carried to the next year

Remarks

January to March

April to June July to September

October to December

11 12 13 14 15 16

Forms under




Overtime Muster Roll Exempted Workers Month ending..........20..

No. in Register Name Department Dates on which overtime has been worked

Extent of overtime on each occasion


production in case of piece workers

Normal Hours

1 2 3 4 5 6 7

Normal rate

of Pay Overtime rate of

pay Normal earning

Overtime earning

* Cash equivalent of advantage accruing

through the concessional sale of food grains and other

articles

Total earning Dates on which overtime

payments made

8 9 10 11 12 13 14

Forms under



FORM NO. 10(A) (Prescribed under Rule 78A)

Overtime Slip for Overtime Work

Month ending..................20…

No. in Register Name Department Dates on which overtime work has been done

Extent of C.T. work on each date

Total C.T. work or prdts in case

of piece workers

Normal Hours

1 2 3 4 5 6 7

Normal rate of Pay

Overtime rate of pay Normal earning Overtime earning Total earning Dates on which overtime payments

made

8 9 10 11 12 13

Forms under



FORM NO. 11(A) (Prescribed under Rule 79)

Notice of Periods of Work for Adults Name of Factory ...........

Where Situated............

On ordinary working days……….

Hours of starting work..........

Hours of closing work..........

(Signed) ............

Period of rest interval From ...... To ......... Manager

On half working days .........

Hours of starting work........

Hour of closing work.........

Date on which notice first exhibited....

Forms under



FORM NO. 11(b) (Prescribed under Rule 76)

Notice of Periods of Work for Adult Workers Name of Factory .......……………………Place........... ……………………………..District ......................................................

Period of Work

Men

Groups Total number of men employed Total number of women employed

Group letter

Nature of Work

Remarks A C D E E F G H I J

Relays 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

On working day ;‐

From

To

On partial working days;‐

From

To

To

A B C D E F G H I J

Dated on which notice first exhibited.................. (Signed) .................

Forms under



FORM NO. 12 (Prescribed under Rule 80) Register of Adult Workers

Serial No.

Name Fatherʹs Name

Residential Address

Nature of Work

Letter of

group as in Form No.

Number of relay, if

working in shifts

Number and date of Certificate, if an adolescent

Number of Certificate and Date

Token Number giving

reference to the

Certificate

Remarks

1 2 3 4 5 6 7 8 9 10

Forms under




Notice of Periods of Work for Child Workers Name of Factory ..........................................................Place ....................................................District .........................................

Periods of Work

Children

Total number of children employed

Description of groups

Groups A B C

Relays 1 2 1 2 1 2 Group Letter

Nature of Work

Remarks

From .......

To ........

Dated on which this notice is first exhibited ............

Manager (Signed) ..............

Forms under



FORM NO. 14 (Prescribed under Rule 86) Register of Child Workers

Serial No.

Name Fatherʹs Name

Residential Address of

Child worker

Date of first employment

Number of

certificate and its date

Token Number giving

reference to the

Certificate

Letter of

group as in Form No.

Number of relay,

if working in shifts

Remarks

1 2 3 4 5 6 7 8 9 10

Forms under



FORM NO. 15 (Prescribed under Rule 87 & 88 ) Register of Leave with Wages

Serial No. ......... Name of factory...... Adult/ Child .......

Department........ Name..........

Serial No. in the Register of Adult/ Child workers.... Fatherʹs Name .....

Date of entry into service,.... Date of Discharge......

Date of amount of payment in lieu of leave due ......

Number of days worked during the calendar year

Leave to Credit

Calendar year of Service

Wage Period

From... To......

Wages earned during the wages period

No. of days of work performed

No. of days of day‐off

No. of days of maternity leave

No. of days leave enjoyed

Total of col. 4 to 7

Balance of leave from preceding year

Leave earned during the year mentioned in col. 1

1 2 3 4 5 6 7 8 9 10

Total of cols. 9 to 10

Whether leave in accordance with scheme under section 79(8) was refused

Leave enjoyed

From.... to......

No. of days.........

Balance of leave to credit

Normal rate of wages

Cash equivalent of advantage according through concessional sale of food grains & other articles

Rate of wages for the leave period (total of cols. 15 & 16)

Remarks

11 12 13 14 15 16 17 18

Forms under



FORM NO. 16 (Prescribed under Rule 87 & 88 )

Leave Book Shall be the same as Register of Leave with Wages (Form No. 15 but shall be made out separately for each worker on a thick bound sheet)

Forms under




Health Register (In respect of persons employed in occupations declared to be dangerous operations under Section 87) Name of Certifying Surgeon :

a. Shri ............. From ......... To...........

b. Shri ............. From ......... To...........

c. Shri ............. From ......... To...........

Serial No.

Work No.

Name of Worker

Sex Age (last birthday)

Date of employment on present work

Date of leaving or transfer to other work

Reason for leaving transfer or discharge

1 2 3 4 5 6 7 8

Nature of Job or

occupation

Raw material or Byproduct handled

Dates of medical Examination by

Certifying Surgeon

If suspended from work,

state period of suspension with detailed

reasons.

Recertified fit to resume

duty on (with signature of Certifying Surgeon)

If certifying of unfitness or suspension issued t o worker

Signature with date of Certifying Surgeon

Results of medical examination

9 10 11 12 13 14 15

Note :‐

i. Column 8. Detail summery of reasons for transfer or discharge should be stated. ii. Column 11. Should be expressed as fit/ unfit/ suspended.

Forms under



FORM NO. 17A (Prescribed under Rule 56A)

Test Report ................ Dust Extraction System

1. Description of system 2. Hood

a. Serial No. of Hood. b. Contaminant captured. c. Capture velocities (at points to be specified). d. Volume exhausted at Hood. e. Hood static pressure Design Actual Value

3. Total pressure drop at

a. Joints b. Other points of system (to be specified)

4. Transport Velocity in Dust (at points alone dust to be specified) 5. Air cleaning Device.

a. Type used. b. Velocity at inlet. c. Static Pressure at inlet d. Velocity at outlet. e. State Pressure at outlet.

6. Fan. a. Type used. b. Volume handled. c. Static pressure. d. Pressure drop at outlet of fan.

7. Fan Motor. a. Type. b. Speed and horse Power.

8. Particulars of defects, if any, disclosed during test in any of the above components.

I certify that on this............day of ............the above dust extraction system was thoroughly cleaned and (so far as its construction permits) made accessible for thorough examination. I further certify that on the said date, I thoroughly examined the above dust extraction system including its components and that the above is a true report of my examination.

Signature ............

Qualification...........

Address ...............

Date ...............

If employed by a Company or Association give name and address……………………………………

Forms under




Notice of Accident or Dangerous Occurrence Resulting in Death or Bodily Injury

(To be sent forthwith to the Inspector of Factories) (See Instruction below)

This space to be completed by Inspector of Factories

District……………………………

Date of Receipt……………………………………..

Number of Accident or dangerous Occurrences…………………………….

Industry No………………………………….

Causation No………………………………………………

Sex (M.W.B., or G)…………………………………………..

Other particulars (e.g. fatel, leg injury, arm injury etc.)…………………………………….

Date of Investigation……………………………………………

Result of Investigation……………………………………………

1. Name of Factory

2. Address of Works where accident or dangerous occurrence happened

3. Nature of Industry

4. Branch or Department and exact place where the accident or dangerous, occurrence happened.

5. Injured personʹs name and address

6.

a. Sex

b. Age (last birthday and)

c. Occupation of injured person

7. Date and hour of accident or dangerous occurrence

8. Hour at which he started work on day of accident or dangerous occurrence.

9.

a. Cause or nature of accident or dangerous occurrence (a)

b. If caused by machinery:

i. Give name of the machine and part causing the accident or dangerous occurrence, and (b) (i)

ii. State whether it was moved by mechanical power at the time (b) (ii).

c. State exactly what injured person was doing at the time (e)

Forms under



10. Nature and extent of injuries (e.g.) fatel, loss of finger, fracture of leg, scald, scratch followed by ...............................................Sepsis ..................................................

11. If accident or dangerous occurrence is not fatal, state whether injured person was disabled for 48 hour or more ...............................

12. Name of medical officers in attendance or injured person.

I Certify that to the best of my knowledge and belief the above particulars are correct in every respect.

Signature of Occupier or Manage

Date of despatch of report…………..

Note: ‐ To be completed in legible handwriting or preferably typewritten.

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EXTRACT FROM THE FACTORIES Act, 1948

Notice Certain Accidents (Section 88)

1. Where in any factory an accident occurs which causes death, or which cause any bodily injury by reason of which the person injured is prevented from working for a period of forty‐eight hours or more immediately following the accident, or which is of such nature as may be prescribed in this behalf, the manager of the factory shall send notice thereof to such authorities, and in such form and within such time, as may be prescribed.

2. Where a notice given under sub‐section (1) relates to an accident causing death, the authority to whom the notice is sent shall make an inquiry into the occurrence within one month of the receipt of the notice or, if such authority is not the Inspector cause the Inspector, to make an inquiry within the said period

3. The State Government may make rules for regulating the procedure at inquiries under this section.

EXTRACT FROM DELHI F ACTORIES, RULES 1950

(Rule 96 prescribed under Sections 38 and 88‐A)

1. When any accident which results in the death of any person or which result in such bodily injury to any person as is likely to cause his death or any dangerous occurrence specified in the Schedule takes place in a factory, the manager of the factory shall forthwith send a notice thereof by telephone, special messenger or telegram to the Inspector and the Chief Inspector.

2. When any accident or any dangerous occurrence specified in the Schedule, which results in the death of any person or which result in such bodily injury to any person as is likely to cause his death, takes place in a factory, notice as mentioned in sub‐rule (i) shall be sent also to :‐

a. the District Magistrate or sub‐Divisional Officer.

b. the officer‐in‐charge of the nearest police station, and

c. the relatives of the injured or deceased person.

3. Any notice given as required under sub‐rules (1) and {2) shall be confirmed by the manager of the factory to the authorities mentioned in these sub‐rules within 12 hours of the accident or the dangerous occurrence by sending the written report in Form No.18 in the case of an accident or dangerous occurrence causing death or bodily injury to any person and in Form 18‐A in the case of dangerous occurrence which has not resulted in any bodily injury to any person.

4. When any accident or dangerous occurrence specified in the Schedule takes place in a factory and it causes such bodily injury to any person as prevents the person injured from working for a period of 48 hours or more immediately following the accident or the dangerous occurrence, as the case may be, the manager of the factory shall send a report thereof to the Inspector in Form No.18 within 24 hours after the expiry of 48 hours from the time of the accident or the dangerous occurrence.

Provided that if in the case of any accident or dangerous occurrence, death occurs of any person injured by such accident or dangerous occurrence after the notices and reports referred to in the foregoing sub‐rules have been sent the manager of the factory shall forthwith send a notice thereof by telephone, special messenger or

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telegram to the authorities and persons mentioned in sub‐rules (1) and (2) and also have this information confirmed in writing within 12 hours of the death.

Provided further, that, if the period of disability from working for 48 hours or more referred to in sub‐rule (4) does not occur immediately following the accident, or the dangerous occurrence, but later on occurs in more than one spell, the report referred to shall be sent to the Inspector in the prescribed form 18 within 24 hours immediately following the hour when the actual total period of disability from working resulting from the accident or the dangerous occurrence becomes 48 hours.

SCHEDULE

The following classes of dangerous occurrence, whether or not they are attended by personal injury disablement:

a. Bursting of a plant used far containing or supplying steam under pressure greater than atn1ospheric pressure.

b. Collapse or failure of a crane, derrick, which hoist or other appliances used in raising or lowering persons or goods, or any part thereof, or the overturning of a crane.

c. Explosion. fire, bursting out, leakage or escape of any molten metal, or hot liquor or gas causing bodily injury to any person or damage to any room or place in which persons are employed, or fire in rooms of cotton pressing factories when a cotton opener is in use.

d. Explosion of a receiver or container used for the storage at a pressure greater than atmospheric pressure of any gas or gases (including air) or any liquid or solid resulting from the compression of gas.

e. Collapse or subsidence of any floor, gallery, roof, bridge, tunnel, chimney, wall, building or any other structure.

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FORM NO. 18A (Prescribed under Rule 96)

Vide para 2 of Schedule Under Rule 96) (Notice of Dangerous Occurrence which does not Result in Death or Bodily injury)

1. Name and address of the factory

2. Name of the Occupier

3. Name of the Manager

4. Nature of Industry

5. Branch or Department and exact place where the dangerous occurrence took place

6. Date and Hour of occurrence

(State exactly what happened)

I certify that, to the best of knowledge and belief the above particulars are correct in every respect.

Note:‐ To be completed in legible handwriting or preferably typewritten. (This space to be completed by Inspector of Factories).

District Date of receipt

D.O.No.

Date of Investigation

Causation No.

Result of Investigation

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FORM NO.19 (Prescribed under Rule 97)

Notice of Poisoning or Disease

(See Instruction on reverse)

Factory Particulars

Person Affected

General Particulars

1. Name of Factory

2. Address of factory

3. Address of office or private residence of occupier

4. Nature of industry

5. Name and Works Number of Patient

6. Address of Patient

7. Sex and Age of Patient

8. Precise occupation of Patient

9. Nature of Poisoning or Disease from which patient is suffering

10. Has the case been reported to the Certifying Surgeon

Signature of Factory Manager

Dated

To be filled in by the Chief Inspector, No. of case Remarks

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NOTICE OF POISONING DISEASE

Extract from the Factories Act, 1948

(Section 89)

Where any worker in a factory contracts any disease specified in the Schedule, the manager of the factory shall send notice thereof to such authorities, and in such form and within such time, as may be prescribed.

Extract from Delhi Factory Rules,1950

(Rule 97)

A notice in Form No. 19 should be sent forthwith both to the Chief Inspector and to the Certifying Surgeon, by the Manager of a factory in which there occurs a cast lead, phosphorous, mercury, manganese, arsenic, carbon disulphide or benzene poisoning or poisoning by nitrous fumes, or by halogens or halogen derivatives of the hydrocarbon of aliphatic series, or of chrome ulceration, anthrax silicosis, toxic anaemia, toxic jaundice, primary optheliomatous cancer of the skin or pathological manifestations due to radium or other radio active substance or X‐rays.

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FORM NO. 20 (Prescribed under Rule No.99)

Abstract of Factories Act, 1948 and The Delhi

Factories Rules, 1950

(To be fixed in a conspicuous and convenient place at or near the main entrance to the factory)

Interpretation

ʺFactoryʺ means any premises including the precincts thereof‐

i. whereon ten or more workers are working, or were working on any day of the preceding twelve months, and in any part of which a manufacturing process is being carried on with the aid of power, or is ordinarily so carried on, or

ii. whereon twenty or more workers are working or were working on any day of the preceding twelve months, and in any part of which a manufacturing process is being carried on without the aid of power, or is ordinarily so carried on, but does not include a mine subject to the operation of the Indian Mines Act, 1923 (IV of 1923), or a railway running shed.

ʺWorkerʺ means a person employed, directly or through any agency, whether for wages or not in any manufacturing process or in cleaning any part of the machinery or premises used for a manufacturing process in any other kind of work incidental to, or connected with the manufacturing process, or the subject of the manufacturing process.

ʺManufacturing processʺ means any process for making, altering, repairing ornamenting, finishing, packing, oiling, washing, cleaning, breaking up, demolishing, or otherwise treating or adopting any article or substance with a view to its, sale, transport, delivery or disposal, or pumping oil, water or sewage, or generating, transforming power or composing types for printing, printing by letter press, lithography, photogravure or other similar processes or book binding or constructing reconstructing, repairing, refitting, finishing or breaking up ships or vessels.

Working hours, holidays, intervals for rest, etc.

1. Hours of work (Adults). Sections 51 and 54‐ No Adult worker shall be required, or allowed to work in a factory for more than 48 hours in any week and for more than 9 hours in any day, or with the previous approval of the Chief Inspector, the daily maximum specified in Sec. 51 may be exceeded in order to facilitate the change of shifts.

2. Relaxation of hours of Work (Adults). Section 64‐ The ordinary limits on working hours of adults may be relaxed in certain special cases, e.g. workers engaged on urgent repairs; in preparatory or complementary work which must necessarily be carried on outside the limits laid down for the general working of the factory, in work which is necessarily so intermittent that the intervals during which they do not work while on duty ordinarily amount to more than the intervals for rest in work which for technical reasons must be carried on continuously throughout the day; in making or supplying articles of prime necessity which must be made or supplied every day; in a manufacturing process which cannot be carried on except during fixed seasons, or at times dependent on the irregular action of natural forces in engine rooms or boiler houses or in attending to power plant or transmission machinery, or in printing of news paper held upon account of the breakdown of machinery, or the loading or unloading of railway wagons.

Except in the case of urgent repairs, the relaxation shall not exceed the following limits‐

i. the total number of hours of work in any day shall not exceed ten;

ii. the total number of hours of overtime work shall not exceed 50 for anyone quarter;

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iii. the spread over inclusive of intervals for rest shall not exceed 12 hours in anyone day.

In the case of any or all adult workers in any factory, the ordinary limits on working hours of adults may be relaxed, for a period or periods not exceeding in the aggregate 3 months in any year, to enable the factory to deal within exceptional press of work.

3. Payment for Overtime. Section 59‐ Where a women works in a factory for more than 9 hours in any day or for more than 48 hours in any week he shall, in respect of overtime work, be entitled to wages at the rate of twice his ordinary rate wages.

4. Exemption of supervisory Staff. Section 64‐ Chapter VI of the Act‐ Working hours of adults‐does not apply to persons holding position in a factory.

5. Weekly Holiday (Adult). Section 52‐ No adult worker shall be required or allowed to work in a factory on the first day of the week unless he has, or will have, a holiday for a whole day on one of the three days immediately before or after the said day, and the manager of the factory has, before the said day or the substituted day, whichever is earlier, delivered a notice at the office of the Inspector of his intention to require the worker to work on the said day and of the day which is to be substituted, and displayed a notice to that effect in the factory.

Provided that no substitution shall be made which will result in any worker working for more than ten days consecutively without a holiday for a whole day.

Where a worker in a factory, as a result of exemption from the ordinary provision relating to weekly holidays is, deprived of any of the weekly holidays he shall be allowed, within the month in which the holidays were due to him or within the two months immediately following that month compensatory holidays of equal number of the holidays so lost.

6. Intervals for Rest (Adults). Sections 55 and 56‐ The periods of work of adult workers in a factory each day shall be so fixed that no period shall exceed 5 hours before he has had an interval for rest of at least half hour and that inclusive of his intervals for rest they shall not spread over more than 10 hours in any day or, with the permission of the Chief Inspector in writing, 12 hours.

7. Prohibition of Double Employment. Sections 60,71 and 99‐ No child or, except in certain circumstances an adult worker, shall be required or allowed to work in any factory on any day on which he has already been working in any other factory.

If a child works in a factory on any day on which he has already been working in another factory, the parent or guardian of the child or the person having custody of or control over him or obtaining any direct benefit from his wages shall be punishable with fine, which may extend to Rs. 50 unless it appears to the court that the child so worked without the consent or connivance of such parent, guardian or person.

8. Prohibition of Employment of Children under 14 Section 67‐ No child who has not completed his fourteenth year shall be required or allowed to work in any factory.

9. Hours of Work (Children). Section 71‐Nochild shall be employed or permitted to work in any factory for more than 4‐1/2 hours in any day and between the hours of 7 P.M. and 6 A.M. The period of work of all children employed in a factory shall be limited to two shifts which shall not overlap or spread over more than 5 hours each and each child shall be employed in only one of relays

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The provision relating to weekly holidays shall also apply to child workers and no exemption from this provision may be granted in respect of any child.

10. Prohibition of Employment of Women. Section 66‐ No Woman shall in any circumstances be employed in any factory more than 9 hours in any day or between the hours of 7 P.M. and 6 A.M. There shall be no change of shifts except after a weekly holiday or any other holiday.

Leave with wages

11. Leave with Wages. Section 79 and 80/83 and Rules‐ Every worker who has worked for a period of 240 days or more in a factory during a calendar year shall be allowed during the subsequent calendar year, leave with wages for a number of days calculated at the rate of‐

i. if an adult, one day for every twenty days of work performed by him during the previous calendar year;

ii. if a child, one day for every 15 days of work performed by him during the previous calendar year;

Any days of layoff, by agreement or contract, or as permissible under the standing orders; in case of a female worker, maternity leave for any number of days not exceeding twelve weeks, and the leave earned in the year prior to that in which the leave is enjoyed shall be deemed to be days on which the worker has worked in a factory for the computation of the period of 240 days or more but he shall not earn leave for these days.

The leave admissible under Sec. 79 shall be exclusive of all holidays, whether, occurring during or at either end of the period of leave.

A worker whose service commences otherwise than on the first day of January, shall be entitled to leave with wages at the rate laid down in Sec. 79 (i) if he has worked for two‐thirds of the total days in the remainder of the calendar year.

If a worker is discharged or dismissed from service during the course of the year he shall be entitled to leave with wages at the rates laid down in Sec. 79 (1) even if he has not worked in the entire calendar year.

Fraction of leave of half a day or more shall be treated as one full dayʹs leave and fraction of less than half a day shall be omitted.

If a worker does not in anyone calendar year take the whole of the leave allowed to him, any leave not taken by him shall be added to the leave to be allowed to him in the succeeding calendar year provided total number of days of leave that may be carried forward to a succeeding year shall not exceed thirty in case of adult and forty in the case of a child. Unavailed leave shall be carried forward without any limit provided a worker who has applied for leave with wages but has not been given such leave in accordance with any scheme laid down under Sec. 79(8), (9).

A worker may at any time apply in writing to the manager of a factory not less than fifteen days before the date on which he wishes leave to being and thirty days before that date if he is employed in a public utility service provided that the number of time in which leave may be taken during any year shall not exceed three. If a worker wants to avail himself of leave with wages due to him to cover a period of illness he shall be granted leave even if application is not made within the time specified above.

An application for leave with wages which does not contravene any scheme lodged under sec. 79 (8), (9) shall not be refused if it is made within the time specified above.

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If the employment of a worker who is entitled to leave under Section 79 terminated by the occupier before he has taken the entire leave to which he is entitled, or if having applied for and having not been granted such leave, the worker quits his employment before he has taken the leave, the occupier of the factory shall pay him the amount payable in respect of the leave not taken and such payment shall be made before the expiry of the second working day on which his employment is terminated.

Unavailed leave of a worker shall not be taken into consideration in computing the period of any notice required to be given before discharge or dismissal.

The manager shall maintain a leave with wages register in the prescribed Form No.14 and shall provide each worker with a book called the ʹLeave Bookʹ in the prescribed Form No.15. The Leave Book shall be the property of the worker and the manager or his agent shall not demand it except to make entries of the dates of holidays or interruptions in service and shall not keep it for more than a week at a time. If a worker loses his Leave Book, the manager shall provide him with another copy on payment of one anna and shall complete it from his record.

Health

12. Cleanliness. Section 11‐ Except in cases specially exempted all inside walls and partition, all ceilings or tops of rooms and all walls, sides arid tops of passages and staircases in a factory shall be kept white‐washed or colour‐washed. The white‐washing or colour‐washing shall be carried out at least once in every period of fourteen months. The floors of every workroom shall be cleaned at least once in every week by washing using disinfectant, where necessary or some other method.

13. Disposal of Wastes & Effluents. Section 12‐ Effective arrangement shall be made in every factory for the disposal of wastes and effluents due to the manufacturing process carried on therein.

14. Ventilation and Temperature. Section 13‐ Effective and suitable provision shall be made in every factory securing and maintaining in every workroom adequate ventilation by the circulation of fresh air and such a temperature as will secure to workers therein reasonable conditions of comfort and prevent injury to health.

15. Overcrowding. Section 16‐ Unless exemption has been granted, there be in every workroom of a factory in existence on 1st April, 1949 at least 350 cubic feet and of a factory built after this date at least 500 cubic feet of space for every worker employed therein and for this purpose no account shall be taken of any space which is more than 14 ft, above the level of the floor of the room,

16. Lighting. Section 17‐ In every part of a factory where workers are working or passing, there shall be provided and maintained sufficient and suitable light, natural or artificial or both.

17. Drinking Water .Section 18‐ In every factory effective arrangements shall be made to provide and maintain in suitable points, conveniently situated for all workers employed therein, a sufficient supply of wholesome drinking water,

In every factory wherein more than 250 workers are ordinarily employed the drinking water shall during the hot weather, be cooled by ice or other effective methods. The cooled drinking water shall be supplied in every canteen. Lunch room and rest room and also at conveniently accessible points throughout the factory,

18. Latrines and Urinals. Section 19 and Rules‐In every factory sufficient latrine and urinal accommodation of the prescribed type (separate enclosed accommodation for male and female workers) shall be provided conveniently situated and accessible to workers at all times while they are at the factory. Every latrine shall be under cover

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and so partitioned off as to secure privacy and shall have a proper door and fastening. Sweepers shall be employed whose primary duty It would be to keep clean latrine, urinals and washing places.

19. Spittoons. Section 20‐ In every factory, there shall be provided a sufficient number of spittoons of the type prescribed in convenient places and, they shall be maintained in a clean and hygienic condition, No person shall spit within the premises of a factory except in the spittoons provided for the purpose. Whoever spits in contravention of this provision shall be punishable with fine not exceeding five rupees.

Safety

20. Fencing of Machinery. Section 21‐In every factory dangerous parts of machines e.g., every moving part of a prime mover and every fly‐wheel connected to a prime mover etc., shall be securely fenced by safeguards of substantial construction which shall be kept in position while the parts of machinery they are fencing are in motion or in use.

21. Work on or near Machinery in motion. Section 22‐ No women or young person shall be allowed to clean, lubricate, or adjust any part of a prime mover or of any transmission machinery while the prime mover or transmission machinery is in motion, or to clean, lubricate or adjust any part of any machine if the cleaning, lubrication or adjustment thereof would expose the woman or young person to risk injury from any moving part either of that machine or of any adjacent machinery.

22. Employment of young Persons on Dangerous Machinery Section 22‐ No young person shall work at any machine declared to be dangerous unless he has been full instructed as to the dangers arising in connection with the machine and the precautions to be observed and has received sufficient training in work at the machine or is under adequate supervision by a person who has a thorough knowledge and experience of the machine.

23. Casing of new Machinery. Section 26‐ In all machinery driven by power and installed in any factory after 1st August, 1950, every set screw, bolt or key on any revolving shaft, spindle, wheel or pinion shall be so sunk, encased or otherwise effectively guarded as to prevent danger; all spur, worm and other toothed or friction gearing which does not require frequent adjustment while in motion shall be completely encased, unless it is so situated as to be as safe as it would be if it were completely encased.

Whoever sells or lets on hire or as agent of a seller or hirer, causes or procures to be sold or let on hire, for use in a factory any machinery driven by power which does not comply with these provisions, shall be punishable with imprisonment for a term which may extend to three months or with fine which may extend to five hundred rupees or with both.

24. Prohibition of employment of Women and Children near Cotton Openers Section 27

No woman or child shall be employed in any part of a factory for pressing cotton in which a cotton opener is at work.

25. Excessive Weights. Section 34‐ No woman or young person shall unaided by another person, lift, carry or move by hand, any material article, tool or appliance exceeding the following limits :‐

Adult female ‐ 65 Ibs. Adolescent male ‐ 65 Ibs. Adolescent female ‐ 45 Ibs. Male child ‐ 35 Ibs. Female child ‐ 30 Ibs.

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26. Protection of Eyes. Section 35‐ Effective screens or suitable goggles shall be provided for the protection of persons employed in or in the vicinity of processes which involve risk or injury to the eyes from particles or fragments thrown off in the course of the process or which involve risk of injury to the eyes by reason of exposure to excessive light.

27. Precautions in case of fire. Section 38‐ Every factory shall be provided with adequate means of escape in case of fire for the persons employed therein. The doors affording exit from any room shall, unless they are of the sliding type be constructed to open outwards. Every window, door or other exit in affording a means of escape in a case of fire, other than the means of exit in ordinary use shall be distinctively marked. Effective and clearly audible means of giving warning in a case of fire to every person employed in the factory shall be provided. Effective measures shall be taken to ensure that wherein more than twenty workers are ordinarily employed in any place above the ground floor or wherein explosive or highly inflammable materials are used or stored, all the workers are familiar with the means of escape in ease of fire and have been adequately trained in the routine to be followed in such case.

Welfare

28. Washing Facilities. Section 42‐Ineveryfactory adequate and suitable facilities for washing shall be provided and maintained for the use of the workers therein. Such facilities shall include soap and nail brushes or other suitable means of cleaning and the facilities shall be conveniently accessible and shall be kept in a clean and orderly condition.

If female workers are employed, separate facilities shall be provided and so enclosed or screened that the interiors are not visible from any place where persons of the other sex work or pass.

29. Facilities for storing and Drying Clothing. Section 43 and Rule‐In the case of certain dangerous operations e.g., lead processes, liming and tanning of raw hides and skins etc. Suitable places for keeping clothing not worn during working hours and for the drying of wet clothing shall be provided and maintained.

30. Facilities for Sitting. Section 44‐ In every factory suitable arrangements for sitting shall be provided and maintained for all workers obliged to work in a standing position in order that they may take advantage of any opportunities for rest which may occur in the course of their work.

31. First aid and Ambulance Room. Section 45‐ There shall in every factory be provided and maintained so as to be readily accessible during all working hours first‐aid boxes or cupboards equipped with the prescribed contents. Each first aid box or cupboard shall be kept in the charge of a separate responsible person who is trained in first aid treatment and who shall always be readily available during the working hours of the factory.

In every factory wherein more than 500 workers are employed there shall be provided and maintained an ambulance room of the prescribed size and containing the prescribed equipment. The ambulance room shall be in charge of a qualified medical practitioner assisted by at least a qualified nurse and such other staff as may be prescribed.

32. Canteens. Section 46 and Rules‐ In specified factories wherein more than 250 workers are ordinarily employed a canteen or canteens shall be provided and maintained by the occupier for the use of this workers. Food, drink and other items served in the canteen shall be sold on a non‐profit basis and the prices charged shall be subject to the approval of a Canteen Managing Committee which shall be appointed by the Manager and shall consist of an equal number of persons nominated by the occupier and elected by the workers. The number of elected workers shall be in the proportion of 1 for every 1,000 workers employed in the factory provided that in no case shall

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there be more than 5 or less than 2 workers on the Committee. The Committee shall be consulted from time to time on to the quality and quantity of food‐stuffs to be served in the Canteen, the arrangement of the menus, etc.

33. Shelters, Rest Rooms and Lunch Rooms. Section 47‐ In every factory wherein more than 150 workers are ordinarily, employed, adequate and suitable shelters or rest rooms and a suitable lunch room, with provision for drinking water, where workers can eat meals, brought by them, shall be provided and maintained for the use of the workers.

34. Creches. Section 48 and Rules‐ In every factory wherein more than 50 women workers are ordinarily employed, there shall be provided and maintained a suitable room or rooms for the use of children under the age six years of such women. The Creche shall be adequately furnished and equipped and in particular there shall be one suitable cot or a cradle with the necessary bedding for each child, at least one chair or equivalent seating accommodation for the use of the mother while she is feeding or attending to her child and sufficient supply of suitable toys for older children.

There shall be in or adjoining the Creche a suitable wash‐room for the washing of the children and their clothing. An adequate supply of clean cloths, soap and clean towels shall be made available for each child while it is in the Creche. At least half a pint of clean pure milk shall be available for each child on every day it is accommodated in the Creche and the mother of such a child shall be allowed in the course of her daily work suitable intervals to feed the child. For children above two years of age there shall be provided, in addition, an adequate supply of wholesome refreshments. A suitably fenced and shady open air play‐ground shall also be provided for the older children.

35. Welfare Officers. Section 49‐ In every factory wherein 500 or more workers are ordinarily employed the occupier shall employ in the factory such number of welfare Officers as may be prescribed.

Special Provisions

36. Dangerous Operation. Section 87 and Rules‐ Employment of women, adolescents and children is prohibited or restricted in certain operation declared to be dangerous, e.g. manufacture of aerated water, electroplating, manufacture and repair of electric accumulators, glass manufacture grinding or glazing of metals, manufacture and treatment of lead and certain compounds of lead, generating petrol gas from petrol, sandblasting, liming and tanning of raw hides and skins, and certain lead process in Printing Presses and Type Foundries.

37. Notice of Accidents. Section 88 and Rules‐ Where in any factory an accident occurs which causes death or which causes bodily injury by reason of which the person injured is prevented from working for a period of 48 hours or more immediately following the accident or which, though not attended by personal injury or disablement is of one of the following types :‐

i. Bursting of vessel used for containing steam under pressure greater than atmospheric pressure other than plant which comes within the scope of the Indian Boilers Act;

ii. Collapse or failure of a crane, derrick, hoist or other appliances used in raising or lowering persons or goods, or any part thereof, or the overturning of a crane;

iii. Explosion or fire causing damage to any room or place in which persons are employed or fire in rooms of cotton pressing factories, where a cotton opener is in use;

iv. Explosion of a receiver or container used for the storage at a pressure greater than atmospheric pressure of and gas or gases including air or any liquid or solid resulting from the compression of gas;

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v. Collapse or subsidence of any floor, gallery, roof, bridge, tunnel, chimney, wall or building, forming part of a factory or within the compound or cartilage of factory.

The Manager of the factory shall forthwith send notice thereof to the Chief Inspector, if the accident is fatal or of such a serious nature that it is likely to prove fatal, notice shall also be sent to the District Magistrate or the Sub Divisional Officer and the Officer‐in‐Charge of the nearest Police Station.

38. Notice of Certain Diseases. Section 89 and Rules‐ Where any worker in a factory contracts any of the following diseases the Manager of the factory shall send notice thereof forthwith both to the Chief Inspector and the Certifying Surgeon:

Lead, phosphorus, mercury, manganese, arsenic, carbon bisulphide or benzene poisoning by nitrous fumes, or by halogens or halogen derivatives of the hydrocarbon of the aliphatic series; or of chrome ulceration, anthrax, silicosis, toxic anemia toxic jaundice, primary opitheliomatous cancer of the skin, or pathological manifestations due to radium or other radioactive substances or X‐rays.

39. No Charge for Facilities and Conveniences. Section 114‐ No fee or charge shall be realized from any worker in respect of any arrangements or facilities to be provided or any equipments or appliances to be supplied by the occupier under the provision of the Act.

40. Powers of Inspectors. Sections 9 and 82‐ Inspectors have power to inspect factories any time and may require the production of registers, certificates etc, prescribed under the Act and the Rules.

Any Inspector may institute proceeding on behalf of any workers to recover any sum required to be paid by an employer under the provisions relating to leave with wages, which the employer has not paid.

41. Obligations of Workers. Sections 97 and 111‐Noworker in a factory :‐

i. shall wilfully interfere with or misuse any appliance, convenience or other thing provided in a factory for the purposes of securing the health, safety or welfare of the workers therein.

ii. shall wilfully and without any reasonable cause do any thing likely to endanger himself or others, and

iii. shall wilfully neglect to make use of any appliance or other thing provided in the factory for the purposes of securing the health or safety of the workers therein.

If any worker employed in a factory contravenes any of these provisions or any rule or order made there under he shall be punishable with imprisonment for a term which may extend to three months, or which may extend to Rs. 100 or with both.

If any worker employed in a factory contravenes any provision of the Act or any rules or orders made thereunder imposing any duty or liability on workers he shall be punishable with fine which may extend to Rs. 20.

42. Certificates of Fitness. Sections 68, 70 and 98‐ No child who has completed his fourteenth year or an adolescent shall be required or allowed to work in any factory unless a certificate of fitness granted with reference to him is in the custody of the Manager of the factory and such child or adolescent carries, while he is at work, at token giving a reference to such certificate. Any fee payable for such a certificate shall be paid by the occupier and shall not be recoverable from the young person, his parents or guardian.

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An adolescent who has been granted a certificate of fitness to work in a factory as an adult and who while a work in a factory carries a token giving reference to the certificate shall be deemed to be an adult for all the purposes of the provision of the Act relating to the working hours of adult and the employment of young persons. An adolescent who has not been granted a certificate of fitness to work in a factory as an adult shall, notwithstanding his age, be deemed to be a child for all the purposes of the Act.

Whoever knowingly uses or attempts to use, as a certificate of fitness granted to himself a certificate granted to another adolescent to work in a factory as an adult, or who having procured such certificate knowingly allows it to be used or an attempt to use it to be made, by another person, shall be punishable with imprisonment for a term which may extend to one month or with fine which may extend to Rs. 50 or with both.

43. Registers, Notices and Returns. Sections 61, 63, 72, 74, 79, 80 and 110‐ A Register of adult workers in the prescribed Form No.12 and a register of child workers in the prescribed Form No.14 shall be maintained by the Manager of every factory.

A notice of periods of work for adults and a notice of periods of work of children in the prescribed Form No.11 (a) or 11 (b) and 12 shall be correctly maintained and displayed in every factory. No adult worker or child shall be required or allowed to work in any factory otherwise than in accordance with their respective notice of periods of work displayed in the factory.

The Owners Occupiers or Managers of factories shall submit the prescribed periodical returns to the Inspector regularly.

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FORM NO. 21

(NOW FORM NO.34) (Prescribed under sub‐rule (1) of rule 100)

Annual Return

For the Year ending 31st December, 19............

1. Registration number of factory.

2. Name of factory.

3. Name of occupier.

4. Name of the manager.

5. District.

6. Full postal address of factory.

7. Nature of industry.

Number of workers and particulars of employment

8. No. of days worked in year.

9. No. of Man‐days worked during the year.

a. Men.

b. Women.

c. Children.

10. Average number of workers employed daily (See explanatory note).

a. Adults.

i. Men.

ii. Women.

b. Adolescents

i. Male.

ii. Female.

c. Children

i. Male.

ii. Female.

11. Total No. of man‐hours worked including overtime.

a. Men

b. Women

c. Children

12. Average number of hours worked per day work (See explanatory note).

a. Men.

b. Women.

c. Children.

Forms under



13. Does the factory carry out any process or operation declared as dangerous under Section 87. (See rule 95).

Name of the dangerous Process of operations carried on

Average No. of persons employed daily in each of the processes or operations given in Col. 1

(i)

(ii)

(iii) etc.

Leave with wages

14. Total number of workers employed during the year.

a. Men.

b. Women.

c. Children.

15. Number of workers who were entitled to annual leave with wages during the year.

a. Men.

b. Women.

c. Children.

16. Number of workers who were granted leave during the year.

a. Men.

b. Women.

c. Children.

17.

a. Number of workers who were discharged, or dismissed from the service, or quit employment, or were superannuated, or who died while in service during the year.

b. Number of such workers in respect of whom wages in lieu of leave were paid.

18.

a. Number of Safety Officers required to be appointed as per notification under Section 40‐B.

b. Number of Safety Officers appointed.

AMBULANCE ROOM

19. Is there an ambulance room provided in the factory as required under Section 45?

Forms under



CANTEEN

20.

a. Is there a canteen provided in the factory as required under Section 46?

b. Is the canteen provided managed :

i. departmentally, or

ii. through a contractor ?

SHELTERS OR REST ROOMS AND LUNCH ROOMS

21.

a. Are there adequate and suitable shelters or rest rooms provided in the factory as required under Section 47 ?

b. Are there adequate and suitable lunch rooms provided in the factory as required under Section 47 ?

CRECHES

22. Is there a creche provided in the factory as required under Section 48 ?

WELFARE OFFICERS

23.

a. Number of Welfare Officers to be appointed as required under Section 49 ?

b. Number of Welfare Officers appointed. ACCIDENTS

24.

a) Total number of accidents (See explanatory note) :

i. Fatal.

ii. Non‐fatal.

b) Accidents in which workers returned to work during the year to which this return relates.

i. Accidents (workers injured) occurring during the year in which injured workers returned to work during the same year.

(aa) Number of accidents.

(bb) Man‐days lost due to accidents.

ii. Accidents (workers injured) occurring in the previous year in which injured workers returned to work during the year to which this return relates :

(aa) Number of accidents.

(bb) Man‐days lost due to accidents.

c) Accidents (workers injured) occurring during the year in which injured workers did not return to work during the year to which the return relates.

i. Number of accidents.

ii. Man‐days lost due to accidents.

Forms under



SUGGESTION SCHEME

25.

a. Is a suggestion Scheme in operation in the factory

b. If so, the number of suggestions

i. Received during the year

ii. Accepted during the year

c. Amount awarded each prizes during the period

i. Total amount awarded

ii. Value of the maximum cash prize awarded

iii. Value of maximum cash prize awarded

Certified that the information furnished above is to the best of my knowledge and belief, correct.

Signature of the manager

Date.........

Explanatory Notes :

1. The average number of workers employed daily should be calculated by dividing the aggregate number of attendance on working days (that is, men‐days worked) by the number of working days in the year. In reckoning attendance, attendance by temporary as well as permanent employed should be counted, and all employees should be included, whether they are employed directly or under contractors. Attendance on separate shifts (e.g. night and day shifts) should be counted, separately. Days on which the factory was closed for whatever cause, and days on which the manufacturing processes were not carried on should not be treated as working days. Partial attendance for less than half a shift on a working day should be ignored, while attendance for half a shift or more on such day should be treated as full attendance.

2. For seasonal factories, the average number of workers employed during the working season and the off‐season should be given separately. Similarly the number of days worked and average number of man hours worked per week during the working and off‐season should be given separately.

3. The average number of hours worked per week means the total actual hours worked by all workers during the year excluding the rest intervals but including overtime work divided by the product of total number of workers employed in the factory during the year and 52. In case the factory has not worked for the whole year, the number of weeks during which the factory worked should be used in view of the figure 52.

4. Every person killed or injured should be treated as one separate accident. If in one occurrence six persons were injured or killed it should be counted as six accidents.

5. In item 24(a), the number accident which took place during the year should be given in case of non‐fatal accidents only.

Forms under



FORM NO. 22 [Prescribed under sub‐rule (3) of rule 100]

Half‐ Yearly Return Period ending 30th June 20.. / 31st December 20..

Name of Factory

Name of Occupier

Name of Manager

1. District

2. Postal Address

3. Nature of industry

4. Average number of workers employed daily*

Men

Women

Adolescent :

Male

Female

Children :

Male

Female

5. Number of days worked during the half year ending 30th June 20/ 31 st December 20

Signature of Occupier .......... Signature of Manager .......

Date of Dispatch .......... Date of Dispatch ..........................

Forms under



FORM NO.24 [Prescribed under sub‐rule (5) of Rule 100]

Annual Return ‐ Creche

Year ending 31stDecember 20…

1. Industry

2. Name of factory

3. Number of women workers ordinarily employed

4. Number of children admitted in the creche

5. Average daily attendance of children at the creche

a. 2 years and below

b. Above 2 years.

6. Details of facilities provided with regard to :‐

a. Milk

b. Food

c. Clothes

d. Toys

e. Medical Aid

f. Other

7. Details of staff employed

i. Doctors :‐

a. Males

b. Females

ii. Nurses

iii. Teachers

iv. Ayahs

v. Sweepers

8. General remarks.

Signature of Occupier .......... Signature of Manager .......

Date of Dispatch .......... Date of Dispatch ..........................

Forms under




Muster Roll

Name of Factory..........

Place where situated..........

Working Hours

Monday to Friday Saturday

Time of Commencement of work Rest Period

Time of Completion of work

Serial No.

Name Fatherʹs Name

Nature of Work

For the Period ending ... Remarks

1 2 3 4 5 6

Note:‐ Separate page should be used for workers employed during different period of work.

Forms under




Register of Accidents and Dangerous Occurrences

Name of injured persons (if any)

Date of accident or dangerous occurrence

Date of report (in Form No.18) to Inspector

Nature of accident or dangerous occurrence

Date of return of injured person to work

No. of days injured person was absent from work

1 2 3 4 5 6

Forms under



FORM NO. 28 (Prescribed under Schedule VI to Rule 95)

Special Certificate of Fitness

(In respect of persons employed in operations involving use of lead compounds)

Serial No.........

Dated.........

I hereby certify that I have personally examined ............. son of ........................................residing at ................. who is desirous of being employed as ......................in the .................and that his age .................as nearly as can be ascertained from my examination, is ................years, and that he is, in my opinion, fit for employment at work involving the use of lead compounds.

His descriptive marks are :‐

.................................................................... ....................................................................

Certifying Surgeon

I certify that I examined the person mentioned above on

I extend that certificate untill

Signature of Certifying Surgeon

Note, of symptoms of lead poisoning (if any)

Left thumb impression of person examined

Forms under



FORM NO. 29 [Prescribed under Rule 53 (A)]

PART I

1. Name of the Worker .......................................................................................

2. Serial No. as in the register of workers, under section 62 of the act ...............................................

3. Fatherʹs Name.......................................................................................

4. Age and date of birth.......................................................................................

5. Nature of work ........................................................................................

6. Qualifications, if any, or period of service on similar work ............................................

7. Date when tight fitting clothing were provided.........................................

8. Signature or thumb impression of workers........................................

9. Remarks

Signature of Occupier

Forms under

THE DELHI SHOPS AND ESTABLISHMENT RULES, 1954

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ I 1

Forms under


Forms under



INDEX

FORM A Statement Under Section 5 (1)

FORM B Register of Establishments

FORM C Registration Certificate of Establishment

FORM D Notice of Change

FORM E Notice of Close Day or a Change in Close Day

FORM G Register of Employment & Remuneration

FORM H Register of Employment and Remuneration of Employees

FORM I Register of Leave

FORM J Notice of Holiday Under Section 17

FORM K Notice Under Section 33 of the Delhi Shops and Establishments Act, 1954, to be Exhibited Conspicuously at the Premises of the Establishment

FORM L Renewal of Registration Certificate

Forms under



FORM A Statement under Section 5 (1)

(See rule 3) Part I

1. Name of the establishment, if any.........................................

2. Postal address of the establishment.........................................

3. Full name of the occupier or the employer including his fatherʹs name........................................

4. Full name of the Manager, if any including his fatherʹs name........................................

5. Category of the establishment, i.e., whether a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment.........................................

6. Nature of business.........................................

Part II

7. Names of members of employerʹs family, working in the establishment (state separately the names of young persons, if any). ........................................

8. Names of other persons occupying position of management or employees engaged in confidential capacity. ........................................

9. Total number of employees (state separately the number of men, women and/or young persons, if any).

Men Women Young Person

10. Date on which the establishment commenced its work.........................................

11. I hereby declare that the details given above are correct to the best of my knowledge.

Dated .............................................................

Note: This statement shall be sent to the Chief Inspector with such fees as are prescribed in Schedule I.

Signature of the occupier/employer

..........................................................

Received from ........................................Form A with Challan No........................................Signature

Forms under



FORM B Register of Establishments

(See rule 4)

Part I – Shops

Part II – Commercial Establishments

Part III – Residential Hotels

Part IV – Restaurants and Eating House

Part V – Theatres and other place of Public Amusement of Entertainment

l. No.

Registration Certificate No.

Name of the Manager if any

Name of occupier/ employer

Postal address of the establishment

Name of the establishment, if any.

Nature of Business

Number of Members of employer’s family

Male FemaleYoung Persons

1 2 3 4 5 6 7 8 9 10

Sl. No.

Number of other persons occupying position of management or employees engaged in confidential capacity

Total number of employees

Adults

Male FemaleYoung Persons

Date of Inspection

Date of Registration

Date of Renewal

Remarks

1 11 12 13 14 15 16 17 18

Forms under



FORM C Registration Certificate of Establishment

(See rule 4 & 5)

Name of the establishment, if any ............................................................................

Name of the occupier/employer............................................................................

Postal address of the establishment............................................................................

Registration No. ............................................................................

It is hereby certified that the establishment as mentioned herein has been registered as a ..........................................under the Delhi Shops & Establishments Act, 1954, on this ............................................ day of ...................................

Seal Chief Inspector, Shops & Establishments, Delhi

Renewals

Sl. No. Date of Renewal From To Signature of the Chief Inspector of Shops &

Establishments with Seal

1 2 3 4 5

1.

2.

3.

4.

1. Here insert the category of the Establishment.

Forms under



FORM D Notice of Change (See rule 4 & 5)

1. Name of the establishment and/or name of occupier/employer................................................................

2. Full Address ................................................................................................................................

3. Registration Certificate No............................. Dated the ..................... Date of ..................20...............

To,

The Chief Inspector under the Delhi Shops & Establishments Act, 1954

Notice is hereby given that the following change has taken place in respect of information relating to Part I of the Form A which please note.

.........................................................


Note – Notice of change in this form shall be sent together with such fees as are prescribed in Schedule II.

Forms under



FORM E Notice of Close Day or a Change in Close Day

(See rule 8)

To,

The Chief Inspector

Shops & Establishments

Delhi

Name of Establishment ...................................................................................................

Address ...........................................................................................................................

Registration Certificate No. ..............................................................................................

Notice is hereby given that with effect from........................................... the establishment shall observe ........................................... as the close day.

Date ....................................................... .........................................................


Forms under




(See rule 14)

Year...........................Month..........................of..................

Wage Period

(Where Different)………………………………………………………….

Name of Establishment ........................................................................................

Name of Employee ...............................................................................................

Nature of Work ....................................................................................................

Wage Period ........................................................................................................

Father’s Name.......................................................................................................

Rate of Wages .....................................................................................................

Date of Employment .............................................................................................

Date

Hours of Work

Interval for Rest & Meals Hours

worked with the employe

r

Overtime Casual or

sickness Leave Availed during the

Month/ Wage Period

Privilege Leave

Signature of Owner or

Occupier

Remarks

From

To

From

To

Hours Worked

Wages

earned

Leave Due

Leave Availabl

e

Balance

1 2 3 4 5 6 7 8 9 10 11 12 13 14

1.

2.

3.

4.

Forms under



Remuneration Due Deductions Net Amount Payable

Date of Payment

Signature of

Employee

Basic salary or

Wages

Over Time

Other Allowances

If any Total

Fines & Deductions on account of Damage or loss

Other Deductions

Advance Paid

Total

Date Amount

1 2 3 4 5 6 7 8 9 10 11 12

1.

2.

3.

4.

Signature of Employer .................................................................

Forms under


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ I 1 0


(See rule 14)

Part I

Working Hours : From ................. To ........................

Interval : From ................. To ........................

Name of Establishment .................................................................

Registration No. .................................................................

Sl. No. Name

Nature of Work For the Wage Period Ending........ Remarks

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

1.

2.

Sl. No. Name

Nature of Work

For the Wage Period Ending........ Remarks

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

1.

2.

Forms under



Part II

Name of Establishment ..................................................................

Registration No. ............................................................................

Wage Period .................................................................................

Name of the Employees

Designation Basic Salary of

Wages

Remuneration date

1Dearness Allowance

1Other Allowances, if any

Consolidated Salary or Wages

Over time

1 2 3 4 5 6 7

Less Deductions Net

Amount due

Employees Signature or Thumb

Impression

Date of Payment

Advance taken

Fine and deduction on account of Damage

1Other Deduction

Total Deductions

8 9 10 11 12 13 14

Note – These sub‐column may be amended to suit the actual requirement of the Establishment provided the remaining columns and sub‐column are not omitted.

Forms under




(See rule 14)


Name of Employee ...........................................................................

Date of Employment ....................................................................

Casual or sick leave Privilege Privilege Leave

Amount of Leave Requested

Date of Application if any

Leave Availed Total

Leave Availed

Date of Application

Whether Application Granted or Refused Fully or Partly

Leave Availed Total

Leave Availed

Balance at the end of the year From To From To

1 2 3 4 5 6 7 8 9 10 11

Forms under



FORM J Notice of Holiday under Section 17

[See rule 14(2)]


Address ........................................................................................

The person employed in the establishment shall be given a holiday on the day mentioned below in the week following the date of this and until further notice :‐

Sl. No. Name of Employee Day on which Holiday is Allowed

Forms under



FORM K

Notice under Section 33 of the Delhi Shops and Establishments Act, 1954, to be Exhibited

Conspicuously at the Premises of the Establishment

(See rule 14)

Please intimate subsequent change if any in this space

(1) Close Day ...........................................................................................................

Date Effective from ..............................................................................................

(2) Daily Hours of Work Fixed ....................................................................................

(a) On Days other than Saturdays .....................................................................

(b) On Saturdays ................................................................................................

Signature of the Employer or Occupier

Forms under



FORM L (See Rule 5)

Renewal of Registration Certificate

Category of Establishment …………………………………..

Name of Establishment…………………………………………..

Total number of existing employees………………………………

Postal Address ………………………………………………..

To

The Chief Inspector of Shops of Establishments, Delhi

As the period of Registration certificate No. …………………………..originally granted/subsequently renewed is due to expire on……………………….. or has already expired on………………………. I have to request for its renewal.

Dated ……………. Signature of the Occupier/Employer

Note: The application shall be sent along with renewal fee as is prescribed in Schedule I

Forms under

THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ J 1

Forms under


Forms under



INDEX

FORM 1 Exemption under Paragraph 27 of the Scheme FORM 2 Nomination and Declaration Form FORM 3 Contribution Card for Unexempted Establishments only FORM 3A Contribution Card for Unexempted Establishments only FORM 4 Contribution Card for Employees other than Monthly Paid

Employees FORM 5

Return of Employees Qualifying for Membership of the Employeesʹ Provident Fund, Employeesʹ Pension Fund and Employeesʹ Deposit Linked Insurance Fund for the First Time

FORM 5A Return of Ownership to Be Sent to the Regional Commissioner FORM 6 (REVISED)

Return of the Contribution Cards Sent to the Commissioner on the Expiry of the Period of Currency

FORM 6A

Consolidated Annual Contribution Statement (For Unexempted Establishments only)

FORM 7 Omitted by G.S.R. 449, Dated 4th March, 1968 FORM 8 Omitted by G.S.R. 521, Dated 16th August, 1991 (W.E.F. 7‐9‐1991) FORM 9 Application for Review Filed Under Sub‐Section (1) of Section 7B FORM 10 Employeesʹ Provident Fund Organisation Income and Expenditure Account FORM 11 Employees’ Provident Fund Organisation Balance Sheet FORM 12 (REVISED)

Statement of Monthly Contributions

FORM 12A (REVISED)

Statement of Monthly Contributions (For Unexempted Establishments only)

FORM 13 Application for Transfer of E.P.F. Account FORM 13A (REVISED)

Application for Inter‐Regional Transfer of Accounts to be Submitted Through the Present Employer

FORM 14

Application for Financing a Life Insurance Policy out of the Provident Funds Account

FORMS 15

Form of Assignment of Policies under Paragraph 64(1) to be Endorsed On Policy,

FORM 16

Application for Advance from the Fund under Paragraph 68b

FORMS 17 AND 18 Not Printed FORM 19

Application by an Adult Member of the Employees’ Provident Fund Scheme, 1952 for Claiming the Employees’ Provident Fund Dues

FORM 20 For Claiming the Provident Fund Accumulation of Minor/ Deceased Member FORMS 21‐30 Not Printed as These Forms are for Departmental Use] FORM 31

Application for Advance From the Fund

Forms under



FORM 1 THE EMPLOYEESʹ PROVIDENT FUNDS SCHEME, 1952

Exemption under Paragraph 27 of the Scheme I hereby apply for exemption from the operation of all or the following provisions of the Scheme:—

a. ............... b. ............... c. ............... d. ............... e. ...............

1. Name (in block letters) : 2. Occupation : 3. Sex : 4. Religion : 5. Father’s Name : 6. Husband’s Name (for married women only) : 7. Permanent Address : 8. Details of the Provident Fund, gratuity or old age pension :

I declare that all the particulars stated above are true to the best of my knowledge and belief.

Dated the ....................................20.......

Signature or left hand thumb impression in case of both female and male members of the Fund

Certified that the above declaration has been signed by ............................................... employed in

**................................................... before me and that he/she is getting the benefits of provident fund, gratuity or old age pension as above.

Dated………………

............................................................ Signature of the manager or other authorized officer of the Factory/ Establishment Registered No. of the Factory/ Establishment

** Here give the name and address of the factory or other establishment in which employed.

Forms under



FORM 2 (Revised) [Paragraphs 33 and 61(1) of the Employees’ Provident Funds Scheme, 1952, and paragraph 18 of the Employees’

Pension Scheme, 1995]

(For Unexempted/Exempted Establishments)

Nomination and Declaration Form 1. Name (in block letters) : 2. Father’s/Husband’s Name : 3. Date of birth : 4.Sex :

5. Marital Status : 6. Account No. : 7.Address (Permanent) : (Temporary) : 8. (A) Date of joining of EPF Scheme, 1952 : (B) Date of joining of EPF Scheme, 1971: (C) Date of joining of EPF Scheme, 1995:

PART A (EPF)

I hereby nominate the person(s)/cancel the nomination made by me previously and nominate, the person(s) mentioned below to receive the amount standing to my credit in the Employees’ Provident Fund, in the event of my death:

Name and Address of the nominee/nominees

Nominee’s relationship with

the member

Date of Birth

Total amount or share of accumulations in Provident Fund to be paid to each nominee

If the nominee is a minor, name and relationship and address of the guardian who may receive the amount during the minority of nominee

(1) (2) (3) (4) (5)

1. *Certified that I have no family as defined in para 2(g) of the Employees’ Provident Funds Scheme, 1952,

and should I acquire a family hereafter the above nomination should be deemed as cancelled. 2. *Certified that my father/mother is/are dependent upon me.

*Strike out whichever is not applicable.

......................................................................................... Signature or thumb impression of the subscriber. .

Forms under



PART B (EPF)

(Para 18)

I hereby furnish below particulars of the members of my family who would be eligible to receive widow/children pension in the event of my death.

Sl. No. Name and address of the family members

Date of Birth Relationship with the member

(1) (2) (3) (4)

*Certified that I have no family, as defined in para 2(vii) of Employees’ Family Pension Scheme, 1995, and should I acquire a family hereafter I shall furnish particulars thereon in the above form.

I hereby nominate the following person for receiving the monthly widow pension (admissible under para

16(2)(g)(i) & (ii) of employees Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving pension.

Name and Address of the Nominee Date of Birth

Relationship with the member

Date........................ ....................................................... Signature or thumb impression of the subscriber.

*Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER

Certified that the above declaration and nomination has been signed/thumb impressed before me by Shri/Smt./Kumari ................................... employed in my establishment after he/she has read the entries/the entries have been read over to him/her by me and got confirmed by him/her.

................................................................................. Signature of the Employer or other authorised officer of the establishment

Place........................... Designation..................................................

Dated the ...................., 20.....

Forms under



Name and address of the Factory/Establishment or rubber stamp thereof

Note.—Whom you can nominate

A. Under the Employees’ Provident Fund Scheme 1) A member of E.P.F. who is married and/or his father/mother is/are dependant upon him can nominate

only one or more persons belonging to his family as defined below:— a. In the case of a male member, his wife, his children, his dependant parents and his deceased

son’s widow and children; b. In the case of a female member, her husband, her children, her dependant parents, her

husband’s dependent parents, her deceased son’s widow and children.

2) If the member has got no family, or is bachelor, nomination may be in favour of any person or persons, whether related to him or not or even to an institution. If the member subsequently acquires a family such nomination shall forthwith become invalid and the member should make a fresh nomination in favour of one or more persons belonging to his family.

B. Under the Family Pension Scheme 1. On the death of a member of the Family Pension Scheme, his family will be entitled to the benefits

under the Family Pension Scheme. The family is defined as under: i. wife in the case of a male member; ii. husband in the case of a female member; and iii. minor sons and unmarried daughters.

Explanation.—The expression “sons” and “daughters” shall include children adopted legally before death in service.

2. If the member has got no family, the monthly family pension, on the death of the member, will not be paid. However, Life Assurance Benefit will be paid to the person or persons entitled to receive his provident fund accumulations.

Note.— A fresh nomination shall be made by the member on his marriage and any nomination made before such

marriage shall be deemed to be invalid.

Forms under



FORM 3 (For Unexempted Establishments only)

(Paragraphs 35 and 42 of The Employeesʹ Provident Funds Scheme, 1952)

Contribution Card for the Currency Period From.......... To............

1. Account No. ................................................................................................................ 2. Name......................................................... Surname............................................ (In Block Capitals) 3. Father’s/Husband’s Name.......................................................................................... 4. Name and address of establishment......................................................................... 5. Statutory rate of contribution..................................................................................... 6. Voluntary, higher rate of employee’s contribution, if any.................................. 7. Age as on....................................................................................................................... 8. Occupation/Job............................................................................................................ 9. Income per month ...................................................................................................... 10. Permanent/Temporary/Contractual .....................................................................

MONTHS CONTRIBUTIONS

Refund of

advances

Break in membership/ reckonable service

Remarks

MEMBER’S SHARE EMPLOYER’S SHARE

E.P.F. F.P.F. @ 1‐ 1/6%

TOTAL E.P.F. F.P.F. @ 1‐ 1/6%

TOTAL

April May June July August September October November December January February March TOTAL

Dated the............................20.......

Signature of the Employer (Office Seal)]

Forms under



FORM 3A (Revised) (For Unexempted Establishments only)

(Paragraphs 35 and 42 The Employees’ Provident Funds Scheme, 1952 and

Paragraph 19 of The Employees’ Family/Pension Scheme, 1995)

Contribution Card for The Currency Period From 1st April .........20.... To 31st March...... 20....

1. Account No. ................................................................................................................ 2. Name............................................................. Surname.............................................. (In Block Capitals) 3. Father’s/Husband’s Name........................................................................................ 4. Name and address of factory/establishment.................................................... 5. Statutory rate of contribution................................................................................... 6. Voluntary, higher rate of employees’ contribution, if any..................................

Month CONTRIBUTIONS Refund of advances

No. of days/ period of service noncontributing service (if any)

Remarks

Worker’s Share Employer’s share

Amount of wages

E.P.F. E.P.F. difference between 10% 12% and 8.33% ( if any) †

Pension Fund contribution 8‐ 1/3 %

1 2 3 4 4b 5 6 7

March paid in April

(a) Date of leaving service if any.

(b) Reason for leaving

service, if any

May

June

July

August

September

October

November

December

January

February, paid in March

Total

Certified that the total amount of contributions (both shares) indicated in this card i.e., Rs............ has already been

Forms under



remitted in full in EPF A/c. No. 1 (PF. A/c.) and A/ c. No. 10............ vide Note below. Certified that the difference between the total of the contributions shown under columns (3) and (4)(a) and (4)(b) of the above table and that arrived at on the total wages shown in column (2) at the prescribed rate is solely due to the rounding off of contributions to the nearest rupee under the rules. Dated the...........................20...... Signature of Employer

With Office Seal

† Rates now enhanced by EPF (Amendment) Act, 1998

Note.—

1. In respect of the Form (3A) sent to the Regional Office during the course of the currency period for the purpose of final settlement of the accounts of the members who has left service details of date and reasons for leaving service, should be furnished under column 7(a) & (b).

2. In respect of those who are not members of the Pension Fund, the employer’s share of contribution to

the EPF will be 12%,10% or 8.33% as the case may be and is to be shown under column 4(a).]

Forms under


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ J 1 0

FORM 4 (Paragraphs 35 and 42 The Employees’ Provident Funds Scheme, 1952 )

Contribution Card for Employees other than Monthly Paid Employees for the Period From......................... To..............................

1. Account No. .............................................................................................................. 2. Name (in block capitals) ............................................... Surname ......................... 3. Caste .......................................................................................................................... 4. Sex ............................................................................................................................. 5. Date of birth as given in Form 2 ............................................................................ 6. Occupation.............................................................................................................. 7. Father’s Name....................................................................................................... 8. Husband’s name........................................................................................................ (for married woman only) 9. Marital status .............................................................................................................

(whether bachelor, spinster, married, widow or widower) 10. Permanent Address ..................................................................................................

Village ............................., Thana .................... Taluk/Sub‐Division ..................... District................................, State.............................................. Signature or left hand thumb impression of member .........................................

11. Signature of person preparing the card ................................................................ 12. Signature of the Manager of the factory or other establishment .................. 13. Registered Number of the factory or other establishment .............................

....................................................................................................................................... 14. Name and address of the factory or other establishment ..............................

.......................................................................................................................................

Particulars of Employment

Registered number of [factory or other establishment]

Duration of employment Remarks Initials of the employer’s authorized clerk

From To

The employer’s and members contribution should be shown separately for each week

Employer’s / member’s total amount refunded

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6

Week 7 Week 8 Week 9 Week 10 Week 11 Week 12 Week 13 Week 14 Week 15





Week 52 Total contribution of the employer Rs P. Signature of the employer’s Head

Clerk or any Authorised Clerk Total contribution by the member Checked and found correct Grand Total Amount refunded Authorized official of the Office of

the Commissioner

Forms under



FORM 5 (Paragraph 36(2)(a) of The Employeesʹ Provident Funds Scheme, 1952 and

Paragraph 20(4) of the The Employeesʹ Pension Scheme, 1995)

Return of Employees Qualifying for Membership of the Employeesʹ Provident Fund, Employeesʹ Pension Fund and Employeesʹ Deposit Linked Insurance Fund for the

First Time During the Month of............................ (To be Sent to The Commissioner with Form No. 2) (EPF and EPS)

Name and address of factory/establishment:......................................................

Code No. of factory/establishment...................................................

Sl. No.

Account No. Name of the employee (in block capitals)

Fatherʹs Name or Husbandʹs Name (in case of married

woman)

Date of Birth

Sex Date of joining the Fund

Total period of previous

service as on the date of joining the

Fund (Enclose Scheme

Certificate if applicable)

Remarks

1 2 3 4 5 6 7 8 9

Date.......................... Signature of the Employer or other authorised Officer

of the Establishment

Stamp of the Factory/Establishment

1. This Form should be accompanied by declaration and nomination in Form 2 (EPF). 2. All particulars to be filled in CAPITAL LETTERS.

Forms under



FORM 5A (For Exempted/ Unexempted Establishments)

(Paragraph 36‐A of The Employeesʹ Provident Funds Scheme, 1952 and

Paragraph 21 of the The Employeesʹ Pension Scheme, 1995 and Paragraph 1 of The Employees’ Deposit‐Linked Insurance Scheme, 1976 )

Return of Ownership to be Sent to The Regional Commissioner (In Duplicate)

1. Name of the establishment

2. Code Number of the establishment under the U.P/ Employees’ Provident Funds and Miscellaneous Provisions Act, 1952

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 owners or lessees (if by lessees, period of the lease should be indicated)

8 Particulars of owners

Name Age Status* Father’s Name

Residential Address

Date from which in position

( a ) (b ) ( c ) ( d ) ( e ) ( f )

(i)

(ii)

(iii)

*Whether Proprietor, Partner, Mg. Partner, Mg. Director, Director, etc. 9. If on lease, particulars of lessees :

9. If on lease, particulars of lessees :

Name Age Father’s Name Residential Address Date from which in position

( a ) (b ) ( c ) ( d ) ( e )

(i)

(ii)

(iii)

Forms under



10. If registered under the Factories Act, particulars of the Manager/Occupie

Name Age Father’s Name Residential Address Date from which in position

( a ) (b ) ( c ) ( d ) ( e )

A. Occupier: B. Manager: 11. Particulars of the persons mentioned above, who are in charge of, and responsible for the conduct of, the business of the establishment.

Name Age Father’s Name Residential Address

( a ) (b ) ( c ) ( d )

i)

(ii)

(iii)

Signature of the Employer

Designation Seal of the Establishment

Date...................

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.

Forms under



FORM 6 (Revised)

(Paragraph 43 of The Employees’ Provident Funds Scheme, 1952)

Return of the Contribution Cards Sent to The Commissioner on the Expiry of the Period of Currency

From .................... To ............... Name and address of the Factory/Establishment ........................................................... Code No. of the Factory/Establishment ...........................................................................

Sl. No Account No.

Name of the Member (in block letters)

Employer’s Total Contribution

Member’s Total Contribution

Amount refunded

Remarks

EPF FPF at 1 1/6%

Total EPF FPF at 1 1/6%

Total

Rs Rs Rs Rs Rs Rs

1 2 3 4 5 6 7

Total number of cards sent ..................... EPF Total @11/6% Rs. Rs. Rs.

Signature of the employer or other authorised officer of Factory/Establishment. Stamp of the Factory/Establishment

Date....................

Forms under



FORM 6A (Paragraph 43 of The Employeesʹ Provident Funds Scheme, 1952 and

Paragraph 20(4) of the The Employeesʹ Pension Scheme, 1995)

Annual statement of Contribution for the Currency Period from 1st...............................20.........to....................20.........

Name and address of the Establishment...........................................................Statutory rate of contribution %.......... Code No. of the factory Establishment.............................. No. of members voluntarily contributing at a higher rate……

Sl. No.

Account No.

Name of the member (in block capitals)

Wages, Retaining allowance (if any) and D.A. including cash value of food concession paid during the currency period

Amount of workerʹs contributions deducted from the wages

Employerʹs Contribution

EPF difference between 12% or 10% ‐ 81/3%

Pension fund contribution 8‐1/3%

Refund of Advance

Rate of higher voluntary contribution (if any)

Remarks

(1) (2) (3) (4) (5) (6) (7) (8) (9) 10

Forms under



FORM 6A (Continued)

RECONCILIATION OF REMITTANCES

Sl. No.

Month

Amount Remitted Administration Charges at .65% Of Wages

EDLI Admn. Charges 0.01% A/C No. 22.

Aggregate Contributions Cols. 5+6+7 (Rs.)

EPF Contributions including refund of

advances A/c No. 1

Pension Fund contributions A/c No. 10

EDLI Contribution A/c No. 21 Rs.

Admn. Charges A/c No. 2 Rs.

1 March paid in April

Rs. Rs. Rs. Rs. Rs.

2 May Rs. Rs. Rs. Rs. Rs. 3 June Rs. Rs. Rs. Rs. Rs. 4 July Rs. Rs. Rs. Rs. Rs. 5 Aug. Rs. Rs. Rs. Rs. Rs. 6 Sept. Rs. Rs. Rs. Rs. Rs. 7 Oct. Rs. Rs. Rs. Rs. Rs. 8 Nov. Rs. Rs. Rs. Rs. Rs. 9 Dec. Rs. Rs. Rs. Rs. Rs. 10 Jan. Rs. Rs. Rs. Rs. Rs. 11 Feb. Rs. Rs. Rs. Rs. Rs.

12 Feb. paid in March

Rs. Rs. Rs. Rs. Rs.

13 Arrear, if any

Rs. Rs. Rs. Rs. Rs.

Total Rs. Rs. Rs. Rs. Rs. Remarks

1. Total number of contribution cards enclosed (Form 3A Revised) 2. Certified that Form 3A, duly completed, of all the members listed in this statement are enclosed, except

those already sent during the course of the currency period for the final settlement of the concerned members account vide Remarks furnished against the names of the respective members above.

Signature of employer with official seal

NOTE.—

1. The names of all members, including those who had left service during the currency period, should be included in this statement. Where the Form 3A in respect of such members had left service were already sent to the Regional Office for the purpose of final settlement of their accounts, the fact should be stated against the members in the ‘Remarks’ column above thus “Form 3A already sent in the month of ..........20…

2. In case of substantial variation in the wages/contributions of any member as compared to those shown in previous statement, the reason should be explained adequately in the ‘Remarks’ column.

3. In respect of those members who have not opted for Pension Fund their entire employers contribution @ 10or 12% as the case may be shown under column No. 6.

Forms under



FORM 9 Application for Review Filed under Sub‐Section (1) of Section 7B

of the Employees’ Provident Funds and Miscellaneous Provisions Act, 1952

(Paragraph 79A)

For use in Commissioner’s Office

Date of filing or

Date of receipt by post

Registration No.

Signature for Commissioner

1. Name of the Applicant ………………………………………………….

2. Designation of the applicant or his relationship with the factory/establishment (whether owner/partner/

director/manager, etc., to be indicated)………………...........................................................................

3. Name and complete address of the factory/establishment ……………………………………………………

4. Address of the employer for service of notice/summons. …………………………………………………….

5. Particulars of the order against which the review application is filed — ……………………………………

i. Order No. ………………………………

ii. Date of order ……………………………

iii. Passed by ………………………………..

iv. Subject in brief ………………………………

6. Main ground(s) on which the application for review has been made and the relief(s) sought. (If necessary, attach a duly signed statement with copies of the documents relied upon marked as A1, A2, A3 and so on…………………………………………………………………………

VERIFICATION

I................... (name of the applicant) s/o, d/o, w/o................... age .............. working as ................. resident of .................... do hereby verify that the contents of particulars given at Sl. Nos. 1 to 6 above are true to the best of my knowledge and belief and I have not suppressed any material fact. I further declare that—

i. I am filing the application within 45 days from the date of the original order.

ii. I have not preferred any appeal against the original order under the Employees’ Provident Funds and Miscellaneous Provisions Act, 1952.

iii. I am filing with this application, the original document authorizing me to represent the aggrieved person (applicable only in cases where the application is filed by agent, advocate or other representative).

Place........................ Signature. Date........................

Forms under



FORM 10 (Paragraph 36 92)(b) of the Employees’ Provident Funds Scheme, 1952 )

Return of Members Leaving Service during the Month of Name and address of factory /Estt.. ……………………………………… Code No. Sl. No. Account No. Name of

Member (in block letters)

Father’s name (or husband’s name in case of married women)

Date of leaving service

* Reasons of leaving service

Remarks

1 2 3 4 5 6 7

Signature of employer or other authorized officer

Date Stamp of the Factory/ Establishment * Please state whether the member is (a) retiring according to para 69(1)(a) or (b) of the scheme (b) leaving India for permanent settlement abroad (c) retrenchment, (cc) part or ltotal disablement due to employment injury (d) ordinarily dismissed for serious or willful misconduct (e) discharged (f) resigning from or leaving service (g) taking up employment elsewhere. (The name and address of the employee should be stated), (h) death (i) attainment of the age of 58 years. A request for deduction for the account of a member dismissed for serious and willful misconduct should be reported by the following certificate. “Certified that the member mentioned at Serial No…………………. Shri……………………….. was dismissed for serios and willful misconduct. I recommend that the employer’s contribution for…………. should be forfeited from the account in the fund. A copy of the order of dismissal is enclosed.” “Certified that the member mentioned at serial No. ………………… Shri……………………. was paid/not paid retrenchment compensation of rupees ………………………. under the Industrial Disputes Act, 1947. “

Signature of the employer (Also filled in Form No. 5)

Forms under



FORM 11 ( For enexempted establishments only)

(Paragraph 34 of The Employeesʹ Provident Funds Scheme, 1952 and

Paragraph 19 of the The Employeesʹ Family Pension Scheme, 1971)

Declaration by a Person Taking up Employment in an Establishment in Which the Employees’ Provident Fund and Family Pension Scheme are in Force:

I …………………………… ** son/wife/daughter of ………………………… ……………………………………………… (Name) Hereby solemnly declare that ‐ (a) I was last employed in……………………………………………………………………

( Name and full address of the establishment) And left service on ……………………………… (prior to that I was employee……………………….. from ………………date………………….to…………………….date (b) ** I was a member of ……………………………… Provident fund ** and also /** but not __________ of the Family Pension Fund from ………………….. to………………….. and my account number(s) was/were …………………………… /……………………………. / ………………………./ (c) ** I have / have not withdrawn the amount of any Provident Fund / Family Pension Scheme. (d) ** I have /have not drawn any superannuation benefits in respect of my past service from any employer. (e) I have never been a member of any Provident Fund and/or Family Pension Scheme. (f) I am drawing/ not drawing pension under EPS 95. (g) I am a holder / not holder of scheme certificate. (h) Scheme certificate surrendered/ not surrendered Date ………………………

Signature or ** right/left thumb impression of the employee

(To be filled in by the employer only when the person employed had not already been a member of the Employee’s Provident Fund ) Shri……………….. …………………………….is appointed as ……………………………………………… (Name of employee) (Designation) In …………………………………………………………………………………………………………………………..

( Name of factory/establishment) With effect from ……………………………………………………

(date of appointment)

Forms under



Date of completion of 120 actual working days in a period of 6 months or less or six months* continuous service or date of confirmation whichever is earliest. Date of admission as member of Employee’s Provident Fund…………………. Account No………………..

Signature of the Manager or other Authorized officer Date * (1) Strike whichever is not applicable N.B.‐ The principal employer should have filled it up also in respect of employees to be employed by or through a contractor.

(For unexempted establishments only)

Contract Rest Total Total No. of employees …………………………………

Total No. of subscribers ………………………

From……………..to……….No. of days worked

Forms under



FORM 12 (Revised) [Para 38(2) The Employees’ Provident Fund Scheme, 1952 ]

Statement of Contributions for the Month of........................20….

Wage Period From....................................................... To...................................................

Name and Address of the Establishment............................. Code No of the establishment .........................

Sl. No.

A/c. No.

Name of the

member (in block Capitals)

Wages, retaining allowance (if any) and D.A. including cash value of food concession paid to the member during the wage period

Amount of member’s contribution deducted

from the wages

Employer’s Contribution

Remarks

EPF

( a )

FPF 1‐1/6 % ( b)

Total

(c )

EPF

( a )

FPF 1‐1/6 % ( b)

Total

(c )

1 2 3 4 5

6

7

Total amount of contributions including refund of advances......................... Administrative charges......................... Total amount deposited in

i. Account No. 1 Rs. ......................... ii. Account No. 10 Rs. .........................

Bank in which deposited......................... No. and date of Bank Draft/Cheque Reserve Bank of India.........................

Signature of the Employer or other Authorised Officer

Stamp of the Establishment

Dated......................... Note.—

1) The names of existing members should be shown in the list of each month in the consecutive serial order of the account numbers. New members whose names are shown in the return for the first time should be shown at the end with a heading “New Members”. In the case of members transferred from another factory/establishment the name of the factory/establishment from which transferred should be given in the ’Remarks’ column.

2) Mention should be made in column No. 8 above, about member’s rate of voluntary contribution. 3) Variation in wages/contribution with that of previous month should be explained suitably in the Remarks

column.

Forms under



FORM 12A (Revised)

(For Unexempted Establishments only) [Proviso to paragraph 38(2) of The Employees’ Provident Funds Scheme, 1952]

Statement of Contribution for the Month of...............

Name and address of the establishment........................................................................... Code No. of the Establishment..........................................................................................

Total number of subscribers

Wages on which contributions are recovered

Amount of contributions due as per recoveries made in the wages/ acquaintance register Worker’s Share

Employer’s Share

EPF

( a )

FPF 1‐1/6 % ( b)

Total

(c )

EPF

( a )

FPF 1‐1/6 % ( b)

Total

(c )

1

2

3

4

Amount of contributions remitted in Account No. 1 and 10

Total number of subscribers

Worker’s Share

Employer’s Share

Total

EPF

( a )

FPF 1‐1/6 %

( b)

Total

(c )

EPF

( a )

FPF 1‐1/6 %

( b)

Total

(c )

5

6

7

8

1. Total amount remitted in Account No. 1 Rs................................................................

Date of remittance........................................................................

2. Total amount remitted in Account No. 10 Rs................................................. Date of remittance................................................

Forms under



Amount of Adm. Charges due 0.37% of the amount of wages shown in column 2

Amount of Admn. Charges remitted in A/c No. 2

Date of remittance

9

10

11

Name and location of the bank in which remitted or No. and date of the cheque/draft sent to Regional Officer

Whether the triplicate challan receipt is enclosed, if not, state

reason

Remarks

12

13

14

Account No. 1................................................ ………………….................................... Account No. 10.............................................. ………………….................................... Account No. 2................................................ …………………....................................

No. as per last month’s return

(+) No. of New Subscribers—vide Form 5

(–) No. of Subscribers left service—vide Form 10

*Net Total

This should tally with the figure given at the top right hand corner of this Form

Total No. of Employees.............................. Contract ..............Rest ..............Total......... Total No. of Subscribers.............................

Currency period form 1st April, 20..... to 31st March, 20...... Statutory Rate of Contribution...................................... No. of members voluntarily contributing at higher than the statutory rate...............

Signature of the Employer (with official seal)

Date...........................

Notes.—

1) If there is any substantial variation between the wages and amount of contribution shown above and those shown in the last month’s return suitable explanation should be given in the ‘Remarks’ column.

2) If any arrears of contributions or damages are included in the figures under Columns 6 to 8,, suitable details indicating the circumstances, amount, No. of subscribers and the period involved should be furnished in the ‘Remarks’ column or on the reverse.

3) Remittance shall invariably be made by deposits in the State Bank of India or its subsidiaries.

Forms under



FORM 13 Revised For office use only

Date Seal/Reg No…………………….. [Para 57 of The Employee Provident Fund Scheme, 1952]

Application for Transfer of E.P.F. Account

Note.— i. To be submitted by the member to the present employer for onward transmission to the

Commissioner, EPF by whom the transfer is to be effected. ii. In case the P.F. transfer is due from the P.F. Trust of an exempted establishment, the application should be

sent directly by the employer to the P.F. Trust of the exempted establishment, with a copy to the RPFC concerned for details of the Family Pension membership.

To, To, The Commissioner, M/s. ........................................... Employees’ Provident Fund

..................................................... .................................................. .....................................................

[To be filled in, if Note (ii) above is applicable]

Sir,

I request that my Provident Fund balance along with the membership details in Family Pension Fund may please be transferred to my present account under intimation to me.

Necessary particulars are furnished below: 1. Name ...................................................

2. Fathers/husband’s name in case of female..................................................

3. Name and address of previous employer ...................................................

4. EPF account number allotted by previous employer ...................................................

5. With whom the PF account of the previous employer is maintained

With Regional PF commissioner With provident fund trust

.................................................. …………………………………..

6. Previous account number allotted by the employer (if allotted separately) ...................................................

7. Date of leaving service with previous employer ...................................................

8. Date of joining the present employer ....................................................

Date......................... Signature/left hand thumb impression of the member

Forms under



TO BE FILLED IN BY THE PRESENT EMPLOYER

9. Name and address of the establishment……………………………….

10. EPF Code Account No. allotted to the member ………………………….

11. EPF Account No. allotted to the member separately, if any…………………

12. By whom the EPF account of the member in the present establishment is kept:

Being an unexempted establishment i. By Regional Office at............................................(station) ii. Sub‐Regional Office at....... iii. By exempted PF Trust, viz....................................

Being an exempted establishment . ..................................................

iv. By Private PF‐Not covered under Act, viz. .........................

13. By whom the EPF account of the member in present establishment is kept:

(i) PF‐Regional Office at................................................ (ii) PF Sub‐Regional Office at ……………………………..

14. In whose favour transfer is to be effected ..................................................... i.e., payee’s details

Date......................... Signature of Employer/Authorised Official with Office Seal

(FOR THE USE OF P.F. OFFICE ONLY)

A sum of Rs. .........................(Rupees.........................) is authorised for transfer, vide Annexure K (Revised). Transfer proceeds to be sent along with Annexure K (Revised):

By D.D. to the Regional PF Commissioner/Officer‐in‐charge of Sub‐Regional Office a......................

By D.D. to the P.F. Trust of the establishment with reference to details in Serial No. 14 above.

Membership details under Family Pension Fund forwarded to P.F. Regional Office/Sub‐Regional Office at.........................

By transfer entries to the Member’s Ledger Card bearing Number ......................... in the present establishment from the Ledger Card bearing Number......................... of the previous establishment.

Transfer intimation/copy of Annexure K (Revised) to the member placed below:

P.I. No. CLERK S.S/AAO/AO/APFC

Scroll No. Paid by Cheque No. .................................. Dated.................................

Cashier/Clerk S.S A.P.F.C.

Forms under



FORM 13A (Revised) THE EMPLOYEES PROVIDENT FUND SCHEME, 1952

[Para 57]

Application for Inter‐Regional Transfer of Accounts to be Submitted through the Present Employer

To,

The Commissioner, Employees’ Provident Fund ................................................

Sir, I request that the Provident Fund and Family Pension Account may please be transferred to my present account under intimation to me. Necessary particulars regarding Provident Fund and Family Pension Fund are furnished below:

1. Name.............................................................................................................................. 2. Father’s name (or husband’s name in case of married woman)......................... 3. Name and address of previous employer, whether

unexempted/exempted/uncovered........................................................................... 4.

a) Previous Provident Fund Account No. ............................................................. b) Previous Family Pension Fund Account No. ...................................................

5. Date of leaving service with previous employer.................................................... 6. Name and address of the employer......................................................................... 7. Whether unexempted/exempted/uncovered.......................................................... 8.

a) Present Provident Fund Account No. ................................................................. b) Present Family Pension Fund Account No. (if any).........................................

9. Date of joining with present employer.........................

*Signature or left/right‐hand thumb impression of the member

Endorsement to be completed by the forwarding authority

Forwarded with the particulars furnished above duly verified. **(The rules of our private provident fund permit such transfer and hence the transfer may be made. The cheque may be drawn in favour of......................... including/excluding bank collection charges.)

Signature of employer or other authorised officer of the

factory/establishment with official seal

* Left‐hand thumb‐impression in the case of illiterate male member and right‐hand thumb impression in the case of illiterate female member.

** Will apply in case of transfer to uncovered establishment. Note.—In case of transfer to provident fund accumulation to uncovered establishment, the benefit under Family Pension Fund Scheme should be paid to the member.

Forms under



FORM 14 [Para 62 of The Employees’ Provident Fund Scheme, 1952]

Application for Financing a Life Insurance Policy out of The Provident Funds Account

To, The Commissioner, Employees’ Provident Fund .................................................. I.........................son/daughter/wife of ...............................................................................................(Name in block capital) an employee of......................... (name of the establishment) authorise the Commissioner to—

i. withdraw, a sum of Rs. .........................(Rupees.........................) from my Provident Fund Account No. .........................and remit the same to the Life Insurance Corporation of India towards the initial premium in respect of my Life Insurance Policy/proposal for Life Insurance details of which are given herein;

ii. make periodical withdrawal of Rs. ......................... (Rupees.........................) from my Provident Fund Account No. ......................... each time the premium falls due for payment and remit the same to the Life Insurance Corporation of India towards the premia in respect of my Life Insurance Policy, details of which are given herein so as to reach the said Corporation within the time allowed for such payments;

iii. to convert the said insurance policy into a paid‐up one when the credit in my provident fund relating to my own contribution becomes inadequate for the payment of any premium, unless the payment of further premium is arranged by me with the Life Insurance Corporation of India and I inform the Regional Commissioner accordingly;

iv. to pay late fees and/or interest on my own contribution in my Provident Fund Account if any premium cannot be remitted to the said corporation in time because of delay in sending to the Commissioner the policy duly assigned to the Central Board of Trustees of the Employees’ Provident Fund or any other reason for which I or my employer may be responsible.

2. I accept that:

i. the authorisation at Paragraph 1(ii) above shall be effective only when my life insurance policy duly assigned to the Central Board of Trustees, Employees’ Provident Fund has been received by the Commissioner after proper registration of the assignment in the books of the said Corporation,

ii. the said authorisation shall thereafter remain operative till such time as I continue to be a member of the Fund and have enough accumulations to my credit as my own share in the Fund or till the maturity of the policy, whichever is earlier,

iii. the terms of the policy shall not be altered nor shall the policy be exchanged for another policy without the prior written consent of the Regional Commissioner.

3. The policy is enclosed for inspection/will be forwarded when received/has already been assigned to the Central Board of Trustees of the Employees’ Provident Fund and accepted by the Commissioner vide his letter No........................., dated the.........................

4. I am aware that the policy is to be assigned to the Central Board of Trustees of the Employees’ Provident Fund as security within six months of the date of the first remittance by the Fund to the said Corporation and sent to the Commissioner after registration of the assignment in the books of the said Corporation.

5. I declare that:

a) I have been a member of the Fund for the period of not less than two years which is the minimum period for being eligible for financing insurance policy from the Fund.

Forms under



b) The amount standing to my credit in my E.P.F. Account (my own share) is Rs. .........................as on......................... which is sufficient for making payment to L.I.C. for two years.

c) My annual contribution to the fund is Rs. ......................... which is sufficient to pay my yearly premia. d) I propose to nominate the same person as for the P.F.

6. I also declare that the policy is free from any ‘encumbrances’ and the details ofthe *policy/proposal given

herein are correct to the best of my knowledge.

7. Details of the *policy/proposal:

i. Address of the branch office or unit of the Life Insurance Corporation where the policy account* is to

be maintained.

ii. *Policy/proposal No. and date.

iii. Sum assured/proposal to be assured.

iv. Probable date of purchase of the policy.

v. Whether the proposal has been accepted and if so, by what date the first premium is to be paid.

vi. Cost of the policy (in the case of single payment of policy).

vii. Amount of yearly premia.

viii. Due date(s) for payment of premium.

ix. Date of payment of last premium.

x. Whether age has been admitted. If not, state the nature of proof presented to Life Insurance Corporation.

xi. Name(s) of the nominee(s) under section 39 of the Insurance Act, 1938.

xii. Guardian appointed under section 39 of the Insurance Act, 1938 in respect of minor nominees, if any.

xiii. Details of any previous policy already assigned to the C.B.T.,

or “Certified that I have not withdrawn any amount previously for financing out of my provident fund

account.”

xiv. Remarks.

Date.........................

**Signature or left/right thumb impression of the member.

Certified that this form has been *signed/ thumb‐impressed before me by .........................

(Name of member)

Account No. .........................employed in ....................................................................... (Name of establishment)

Signature of the employer or his authorised official Designation.........................

Date......................... Code No. of the Estt. ......................... Name and address of the establishment and its stamp

* Delete portion not applicable.

** Left hand thumb‐impression in the case of illiterate male member and right hand thumb impression by illiterate female member.

Forms under



For use in Regional Commissioner’s Office

(ACCOUNTS SECTION)

Please furnish the following information in respect of the subscriber:

Average of yearly Contribution (employee’s share only) on the basis of recent 12 months Form No. 12

Total contribution (Employee’s share only) as on

Whether any other L.I.P. advance has been granted before. If so, mention the date of withdrawal

Whether the subscriber has contributed for two years

The above case has been examined vide Paragraphs 62 to 64 of the Employees’ Provident Funds Scheme, 1952. A sum of Rs. ......................... (Rupees.........................) may be paid.

Clerk Head Clerk Accounts Officer R.P.F.C.

INSURANCE SECTION D.P. Sheet prepared and put up for signature

Clerk (Ins.) H.C. (Ins.) Accounts Officer R.P.F.C.

Forms under



FORM 15 THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952

Form of Assignment of Policies under Paragraph 64(1) to be Endorsed on Policy I ...................................................... son/daughter/wife of........................................................... hereby assign unto the............................................................................................................ Board of Trustees, Employees’ Provident fund..................................................................... ........................................................................................................... within the policy of assurance as security for payment of all sums which under paragraph 67(1) and 68 of the Employees’ Provident Fund Scheme, I may hereafter become liable to pay to the Fund.

I herewith certify that no prior assignment of the within policy exists dated...........this......................................... Day of.....................20........ Station................................... Account No..........................

*Signature or left/right hand thumb impression of the member.

Witness Certified that this Form has been signed before me by................................................. employed in................................................ Regd. No. of the Factory/Establishment Code No. of the Factory/Establishment Date...........................20.... Signature of the employer or any authorised officer

Designation....................................................

Date......................... Stamp of the Establishment .........................

* Left hand thumb impression in the case of illiterate male member an right hand thumb impression in the case of female member.

Note:—

1. The Policy is required to be assigned within six months after the first withdrawal in respect of it by endorsement thereon in terms of the above Form.

2. While assigning the Policy, the notice hereunder should be given to the Life Insurance Corporation.

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NOTICE

To The Divisional Manager, The Life Insurance Corporation of India. Unit........................................... Subject: Assignment of Policy No........................

Notice is hereby given that policy No............................... for Rs. ................................. on the life of Shri/Shrimati............................................................................................ as on this........................................... day of...................................20.... been assigned in favour of Central Board of Trustees, Employees’ Provident Fund by Shri/Shrimati...........................................

2. The said policy is enclosed. Please have the assignment registered in books and return the policy to the Regional Provident Fund Commissioner.................................... State.

(give complete address)

Yours faithfully, Signature of the Assignee

Full Address

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FORM 16 THE EMPLOYEES’ PROVIDENT FUNDS SCHEME, 1952

Application for Advance from the Fund under Paragraph 68B PART I

(To be completed by the member)

1) Name of the member (in block letters)........................................................................

2) Father’s name (or husband’s name in the case of married woman)........................

3) Name of the Factory/Establishment.......................................................

4) Account No..................................................................................................

5) Rate of monthly basic wages and dearness allowance........................

6) Amount of advance required....................................................................

7) Purpose for which advance is required:

a) *Purchasing a dwelling‐house. b) *Purchasing a dwelling site. c) *Construction of a dwelling‐house. d) *Addition/substantial alteration or substantial improvements necessary to the

dwelling‐house owned by member. e) *Completing the construction of the dwelling‐house already commenced by member. f) *Acquiring a flat in a building.

8) Whether any advance has been sanctioned for any of the purposes mentioned against Serial No. 7. If so, the

date of sanction thereof........................ 9) Area and location of the dwelling site/house intended to be purchased/ constructed/already

purchased/constructed. Whether the site purchased/ intended to be purchased/constructed is within or outside municipal area........................

10) Name and address of the present owner of the dwelling site/house intended to be purchased........................ 11) Present state of the dwelling‐house or the stage at which the construction is now on [to be filled in if the

advance is required for purpose (d) or (e) mentioned against Serial No. 7........................ 12) Desired mode of remittance and the address to which remittance is desired:

a. *By postal money order at member’s cost. b. *By crossed cheque through post. (Please send advance receipt in the enclosed form).

13) List of Documents to be enclosed in case of 7(a) and 7(b)— i. Title Deed of proposed seller. ii. Non‐encumbrance certificate in respect of the dwelling site/house to be purchased. iii. Agreement with the vendor for the purchase of site/house. iv. An estimate of the cost of construction in the case of the advance for the construction of the house.

7(c) and 7(d)—

i. Original title deed for certificate from appropriate revenue authority regarding ownership and

non‐encumbrance of the land. ii. Sanctioned construction plan.

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Conditions 14) I undertake to comply with the following conditions:

i. The amount of advance shall be utilised for the purpose applied for.

ii. If the amount of advance is in excess of the actual expenditure incurred for the purpose for which the advance was granted, the excess shall be refunded to the Fund within 30 days of the finalisation of the purchase or completion of the construction or completion of the additions to the dwelling‐house as the case may be.

iii. If the advance is for construction of dwelling‐house, the construction shall be commenced within six months of the withdrawal of the first installment and completed within six months of the final installment.

iv. If the advance is for the purchase of a dwelling site or house, the purchase shall be completed within six months of the withdrawal.

v. The amount of the advance shall not be utilised for constructing a dewllinghouse on land which is not owned solely by me.

vi. The amount of advance shall not be utilised in purchasing a dwelling site or house which is not free from encumbrances and which is a share in a joint property.

vii. Such title deeds, plans, other documents and information related to the intended purchase, construction or addition as may be called for by Commissioner from time to time shall be furnished to him on demand.

viii. A declaration in the form prescribed by the Commissioner shall be furnished to him immediately on finalisation of the purchase or completion of the construction or addition to the house.

ix. If the purchase or construction for which the advance is granted does not materialise or if there is any breach of the conditions specified herein or in the EPF Scheme the entire amount of the advance together with interest thereon at the rate of 6¼% per annum shall be refunded to the Fund.

DECLARATION 15) I declare that—

i. I have not taken any advance from the fund under Paragraph 68C of the EPF Scheme. ii. The dwelling site/house intended to be purchased out of the advance applied for is free from encumbrances

and is not a share in joint property. iii. *Without the further advance now applied for the construction already commenced cannot be

completed/the additions which are essential cannot be made. iv. I am the sole owner of the land on which I intend to construct a dwelling‐house out of the advance applied

for. v. I have not taken any advance from the Fund under Paragraph 68‐B/68‐B(5).* vi. All requirements of the local authorities in connection with the intended construction/purchase have been

satisfied.

Date............................. **Signature or left/right hand thumb

impression of the member. Postal address:

* Delete terms if not applicable **Left hand thumb impression in the case of illiterate male member and right hand thumb impression in the case of illiterate female member.

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PART II

(To be filled in by the employer)

Certified that the application has been signed by........................ employed in my factory/establishment after *he/she has read the contents/the contents have been explained to him/her by me and that the Account No. and the rate of monthly basic wages given in the application are correct. Following documents furnished by him are enclosed herewith:

i. *Original title deed. ii. *Non‐encumbrance certificate in respect of the dwelling site/house to be purchased, duly signed with

official seal from appropriate revenue authorities. iii. *Extract of Property Register/VII/XII duly signed with official seal by appropriate revenue authority. iv. *Agreement with the vendor for the purchase of the site/house. v. *Sanctioned construction plan and an estimate of the cost of construction in the case of the advance for

construction of the house. vi. *Non‐agricultural use certificate from appropriate revenue authority (in respect of agricultural land)

on which dwelling‐house is proposed to be constructed. vii. *Bank advance receipt duly **signed by the applicant.

Date........................ Signature of the employer or an authorised official of the factory/establishment Regd. No. of the factory/Establishment Designation of the signing official with stamp of the factory/establishment Code No. of the factory/Establishment

* Delete terms if not applicable ** Left hand thumb impression in the case of illiterate male member and right hand thumb impression in the case

of illiterate female member.

PART III.

(For use in Regional Commissioner’s Office)

a. Years of service put in by the member................................................

b. Total of accumulations standing tot he credit of the member as his own share of contribution ........................ as on........................

c. Whether in case of construction of house any proof to show that the land belongs to the member of his/her spouse has been submitted........................

i. Original title deed.

ii. Non‐encumbrance certificate from appropriate revenue authority.

d. Whether in case of purchase of dwelling site/house title deed of the proposed seller has been produced along with an agreement with the vendor for the purchase of site/house as the case may be.

e. Recommendations by the clerk with his dated initials.

f. Recommendations by the H.C. with his dated initials.

g. Recommendations by the Accounts Officer.

h. Orders of the Regional Commissioner.

Payment authorised No........................... Auditor H..C. A.O

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FORM 19 THE EMPLOYEES PROVIDENT FUND SCHEME, 1952 [Para 72(5)]

Form to be used by a Major Member of Employees’ Provident Fund Scheme, 1952 for Claiming The Employees’ Provident Fund Dues

(Refer instructions) 1. Name of the member (in block letters)........................................................................ 2. Father’s name (or husband’s name in the case of married woman)......................... 3. Name and address of the factory/establishment in which the member was last employed............................... 4. Account No. ................................................. 5. Date of leaving service................................ 6. Reason of leaving service............................ 7. Full postal address (in block letters) Sh./Smt./Kumari.........................

S/o./W/o./D/o............................ .........................Pin

8. Mode of remittance [Put a ‘tick’ in the box against the one opted]

a. By postal money order at my cost To the address given against item No. 7 b. By account payee cheque sent

direct for credit to my S.B. A/c. (Scheduled Bank/PO) under intimation to me.

(Advance stamped receipt furnished below)

Certified that the particulars are true to the best of my knowledge. Date of joining the establishment......................... Date of leaving service.........................

CONTRIBUTION FOR THE CURRENT FINANCIAL YEAR

Month Wages Contribution Period of break, if any

Month Wages Contribution Period of break, if any

Employee Employer Total Employee Employer Total EPF FP EPF FP EPF FP EPF FP EPF FP EPF FP

(Information to be furnished by the employer if the claim form is attested by the employer) Certified that the above contributions have been included in the regular monthly remittances. The applicant has signed/thumb‐impressed before me.

Signature of the employer or Signature or left/right hand thumb authorised official impression of the member Designation and seal Date......................... Encl.........................

S.B. Account No. (in figures).............(in words).............................................. Name of the Bank................................. Branch.................................................... Full address of the branch..................

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Declaration of non‐employment

I declare that I have not been employed in any factory/establishment to which the Act applies for a continuous period of not less than 2 months immediately preceding the date of my application for final withdrawal of my Provident Fund money.

Date......................... Signature or left/right thumb impression of the member

Advance stamped receipt

Received a sum of Rs.* ......................... (Rupees*......................... only) from Regional Provident Fund Commissioner/Officer‐in‐charge of Sub‐Regional office ................. ........ by deposit in my savings bank account towards the settlement of my Provident Fund Account.

Signature or left/right thumb impression of the member

* The space should be left blank which shall be filled in by the RPFC/ officer‐in‐charge of sub‐accounts office.

Signature or left/right hand thumb impression of the member

(For the use of Commissioner’s office)

Account settled in part/full entered in Form 21 A/24/2/9 and withdrawal register

Clerk Head Clerk

(P.I. No.)......................... (M.O./Cheque) ......................... Account No. ......................... (Section)......................... under Rs. ......................... [Passed for payment of Rs.........................(in words)]

Accounts Officer

Date.........................

(For use in cash section)

Paid by inclusion in cheque No. ......................... date......................... vide ......................... Cash book (bank) Account No. 10 Debit item no. ......................... Head clerk AC/RC

Affix Re. 1. Revenue stamp

The space should be left blank which shall be filled in by Regional Provident Fund Commissioner/Officer‐in‐charge of S.R.O

M.O. Commission, if any

Net amount paid by M.O. .........................

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Remarks

ACKNOWLEDGEMENT CARD

Account No. Office of the RFFC/Officer‐in‐Charge of Sub‐Regional Office

ACKNOWLEDGEMENT CARD

Received the following claims EPF EPF IF

POSTCARD In case, no intimation is received within a month, you may write to the Complaints Officer, Employees’ Provident Fund duly quoting the Registration Number and your Provident Fund Account Number

Registration No.......................... Date Office Seal......................... ..................................................... ......................................................

......................................................... ......................................................... PIN..................................................

EPFO

Postage Prepaid

Forms under



EMPLOYEES’ PROVIDENT FUND ORGANISATION Office of the Regional Provident Fund

Commissioner/S.R.O. .........................(Full Address)......................................................................

Instructions for filling up the applications (Form 19 & 10B) (For the guidance of applicant only. Not to be sent along with the claims)

1. All the columns in the form should be filled in completely in ink, without any overwriting. 2. Against the column reason for leaving service, indicate the one applicable:

a. Retired from service after attaining the age of 55 years/attained the age of 55 years. b. Retired on account of permanent and total incapacity for work due to Bodily/ Mental infirmity. c. Retired under voluntary retirement scheme. d. Migrating from India for permanent settlement abroad. e. Leaving India at least for a year. f. Retrenched from service. g. Discharged from service on receiving compensation under the Industrial Disputes Act, 1947. h. Resigned, not employed in any factory to which the Employee’s Provident Fund Scheme applies.

3. “Full postal address”, should be given clearly in Block Letters. Since the M.O. & Payment intimation is to be

sent to this address the name of the member and Father’s (Husband’s) should also be furnished in this column. Correct postal address including pin code will enable the Commissioner to make prompt payment to the correct payees.

4. It was advisable to have the payment by cheque. For this purpose the account payee cheque will be sent direct

to the Scheduled Bank in which the S.B. A/c. is maintained under intimation to the member. This will expedite the settlement of the correct payee.

5. The literate member should sign the application form, illiterate male member should affix his left hand thumb

impression and illiterate female member should affix her right hand thumb impression and the fact should be clearly recorded below thumb impression.

6. If the claim is required to be submitted after completing the prescribed period (i.e. in case falling under items

2(g) and (h) above only, the declaration of non‐employment in the application should be completed duly dated.

7. The claim application should be attested and forwarded by the employer under whom the member was last employed.

If the member is unable to send the application through the employer or duly attested by him for and reason whatsoever he may forward the claims duly signed in the presence of any one of the following authorised and got attested over his official seal. (i) Magistrate; (ii) A Gazetted Officer; (iii) Post/Sub‐Postmaster; (iv) President of the Village Union; (v) President of the Village Panchayat where if no Union Board; (vi) Chairman/Secretary/Member of the Municipal /District Local Board (vii) Member of Parliament/Legislative Assembly; (viii) Member of Central Board of Trustee/Regional Committees Employee’s Provident Fund; (ix) Manager of the Bank in which the Saving Bank Account is maintained; (x) Head of any recognised education institution; (xi) any authorised person as may be approved by the Commissioner.

8. The following documents should be enclosed in support of the claim:

If the member retired on account of permanent and total incapacity due to bodily or mental infirmity a medical certificate from the ESI or if the employee is covered under the ESI Scheme, from, the Medical Officer

Forms under



designated by the Establishment should be attached. In case of migration from India for permanent settlement abroad, Visa, Passport, Journey ticket, etc., should be sent for perusal and return.

9. The member should also furnish the address in the acknowledgement card attached to the claim(s).

10. Instructions to the employer before forwarding the claims.

Details of contribution in of the member for the current financial year should be furnished in the certificate portion, in case, the contribution is not already paid it should be remitted by separate challan and receipted triplicate challan should be enclosed to the claim.

11. In support of claim under Employee’s Family Pension Scheme, 1971 the period of break in reckonable service

(i.e. period for which EPF contribution is not payable) should be furnished if not already intimated through contribution card.

Note: If in Form 10‐B (EPF) along proffered S. Nos 2,6 & 8 are not applicable

Forms under



FORM 20 THE EMPLOYEES’ PROVIDENT FUND SCHEME, 1952

(For Claiming the Provident Fund Accumulation if Minor/ Deceased Member)

Regn. No. ......................... (For office use only) Form to be used

1) by the guardian of minor/lunatic member, or 2) by a nominee or legal heir of the deceased member, or 3) by the guardian of the minor/lunatic nominee or heir for claiming the Provident Funds accumulation of

minor/deceased member. Note.—Read the instructions carefully before completing this form.

Particulars of member 1.

a) Name of the member (in Block Letters).........................

b) Father’s name (or husband’s name in case of married woman).........................

c) Name and address of the factory/establishment in which the member was last employed.........................................

d) Account No. ..........................................

e) Date of leaving service.........................

f) Reason of leaving service (in case of deceased member).........................

g) Date of death of the member....................................................................

h) Marital status of the member on the day of death...............................

Particulars of the claimant

2. (To be filled in by a major nominee/legal heir/member of the family of the deceased member) a) Name of the Claimant (in Block Letters).........................

b) Father’s/husband’s name.........................

c) Sex.........................

d) Age (as on the date of death of the member).........................

e) Marital status (as on the date of death of the member).........................

(whether unmarried, married, widow or widower)

f) Relationship with the deceased member.........................

3. (To be filled in by the Guardian/Manager of minor/lunatic member or lunatic minor *[Nominee(s) /legal

heir(s)]/Family member(s) of the deceased member)

a) Name of the claimant (i.e. guardian) .........................

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b) Father’s/Husband’s name.........................

c) Relationship with the member/deceased member.........................

3A. Particulars of the minor/ lunatic nominee(s) /legal heir(s) /family member(s)* on whose behalf the provident fund

amount is claimed.

Sl. No.

Name Sex Age Religion Relationship

With the deceased member With the guardian

4. Claimant’s full postal address Shri/Smt......................... (in block letters) S/o/ W/o/ H/o.......................................

Pin.........................

5. Mode of remittance:

(a) By postal money order at my cost *to the address given in item No. 4

or (b) By account payee cheque sent directfor

credit to my S.B. A/c. (Sch. Bank/Post Office) under intimation Branch......................... to me (Advance stamped receipt Full address of the bank............ furnished below)

Certificate

⎯ To the best of my knowledge no posthumous child will be born to the deceased member. ⎯ I certify that the particulars given above are true to the best of my knowledge. ⎯ I certify that the minor(s) /lunatic Sri/Smt......................... is living with me and is being supported and looked

after by myself and the Provident Fund money claimed on behalf of minor/lunatic will be spent in his/her best interests and benefits.

⎯ I certify that the minor member has not been employed in any factory/ establishment to which the Act applies for a continuous period of not less than 6 months immediately preceding the date of this application.

Enclosures:

Date......................... Signatures or left/right hand thumb

impression of the claimant

* Delete, if not applicable.

Advance Stamped Receipt

SB Account No.

Bank

Branch

Full address of the bank

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[To be furnished only in case of 5(b) above]

Received a sum of Rs.*......................... (Rupees*.........................) from Regional Provident Fund Commissioner/Officer‐in‐charge of sub‐regional office ......................... by deposit in my Saving Bank account towards the settlement of Provident Fund account of Sri/Smt.........................

Signature or left/right hand thumb impression of the claimant

* The space should be left blank which shall be filled in by RPFC/ Officer‐in‐charge of SRO.

Certificate by the attesting authority

CONTRIBUTION FOR THE CURRENT PERIOD

⎯ Certified that the above contributions have been included in the regular monthly remittances. ⎯ Certified that the facts stated above are correct. ⎯ Certified that the claimant Sri/Smt./Kumari......................... is known to me and signed/thumb impressed

before me.

Signature of the employer or any authorized officer designation and office seal.........................

For the use of Commissioner’s office

Account settled in part/full. Entered in Form 21A/24/2/9 (Revised)

Clerk Head clerk P.I. No......................... M.O./Cheque......................... Account No. ........................ Section......................... Passed for payment for Rs......................... (in words) M.O. Commission (if any)......................... Net amount to be paid by M.O. .........................

Accounts officer Date.........................

For use in cash section Paid by inclusion in cheque No. ......................... dated ......................... vide Cash book (Bank) Account No. 3 Debit Item No. ......................... Head Clerk Assistant Commissioner/Regional Commissioner Remarks..................................................................................................................................

......................................................................................................................................................

Affix Re. 1 Revenue stamp

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ACKNOWLEDGEMENT CARD Account No. .........................EPFO Office of the FPFC/Officer‐in‐Charge of Sub‐Regional Office

ACKNOWLEDGEMENT Received the following claims Registration No. ......................... EPF......................... Date......................... FPF......................... Office Seal IF.........................

POST CARD

In case, no intimation is received within a month, you may write to the Complaints Officer Employees’ Provident Fund duly ................................. quoting the Registration Number and your ................................. Provident Fund Account Number.

EMPLOYEES PROVIDENT FUND ORGANISATION

Office of the Regional Provident Fund Commissioner/S.R.O. ......................... Full Address.........................

Instructions

(For the Guidance of applicant only, not to be sent along with the claim)

1. Employees’ Provident Fund Scheme, 1952: Form 20: Claim for the withdrawalof Provident Fund

Accumulation of minor/deceased member. By whom the claim application should be preferred ? 2. If the member is a minor by the guardian.

OR

On death of the member:— a) If nomination subsists: by the nominee(s) if the nominee(s) is/are minor by the guardian of minor(s). b) If no nomination subsists: by the family member’s (family) includes posthumous child if any, except major

sons, and married daughters whose husbands are alive, of the deceased member duly supported by the list of surviving family members (as on the date of the death of the member) furnished by the last employer or mamlatdar/Tehsildar or Executive Magistrate indicating complete particulars such as name, relationship with deceased member (in the case of parents whether dependant or not) age, marital status. If any family member is a minor by the guardian of minor. If both (a) & (b) above are not applicable: by legal heir(s) duly supported by a legal heirship certificate (from the appropriate State normally Revenue authorities).

…………………………………………

………………………………………….

…………………………PIN

Postage Prepaid

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3. Documents to be enclosed: a) if the application is preferred by a guardian other than the natural guardian or minor

member/nominee/family member/legal heir a guardianship certificate issued by competent court of law should be enclosed.

b) Death certificate. c) If the amount receivable exceeds Rs. 5000 but less than 25,000 an affidavit‐cum‐idemnity bond (Form may

be obtained from the ex‐employer of Regional Provident Fund Commissioner or Officer‐in‐Charge of Sub‐Regional Office......................) or Estate Duty Clearance Certificate.

d) If the amount receivable exceeds Rs. 25,000 on Estate Duty Clearance Certificate.

Form 11 (FPF): Claim for benefits as admissible under the Employee’s Pension Scheme, 1971. By whom claim application should be preferred?

i. If the member is minor by his guardian,]

OR

(2) On death of the member: i. If the deceased had ‘family’ on the day of death the claim should be preferred by.

a. the widow or widower. b. failing (a) above, by the guardian or eldest surviving minor son. c. failing (a) and (b) above by the guardian or eldest surviving minor, unmarried daughter.

ii. If the deceased member had no family on the day of death, the Family Pension Fund benefit should be claimed by the person(s) eligible to receive the Provident Fund accumulation of the deceased member and if such member is a minor by the guardian. *(If the claimant being other than the natural guardian a guardianship certificate issued by the court of law should be enclosed.

Important Note:—In case the member died while in service after contributing to the Family Pension Fund for a period of not less than two years, an application in Form 10A should also be preferred for claiming monthly Family Pension.

iii. Form 5(F) ‘Benefit under Employees’ Deposit‐Linked Insurance Scheme, 1976. The benefit under Employees’ Deposit‐Linked Insurance Scheme, 1976 is admissible to the person(s) entitled to

receive the Provident Fund Accumulation of the deceased member only under the following conditions:

1. The death should have occurred while in service and, 2. The average balance in the accounts of the deceased employee should not be below the sum of Rs. 1000

during the preceding three years or during the period of his membership, whichever is less. An affidavit‐cum‐indemnity bond in the prescribed form should be furnished wherever the payment under Employees’ Deposit‐Linked Insurance exceeds Rs. 5000 (if amount receivable under Employees’ Provident Fund and Employees’ Deposit‐Linked Insurance does not exceed Rs. 25,000 one affidavit‐cum‐indemnity bond is sufficient).

GENERAL:

1) All the columns in the form should be filled in, in ink, without any overwriting. 2) Correct postal address, including Pin Code will enable to make prompt payment to the correct payee. 3) The claimant should also furnish the address in the acknowledgment attached to the claims. 4) The literate claimant should sign the application form. In case of illiterate:—Left hand thumb impression by

illiterate male claimant and right hand thumb impression by illiterate female should be affixed in the claim form.

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5) Attestation of claim application:—The application should be submitted through the employer under whom the member was last employed if for any reason, the claimant is unable to submit through the employer, the claim may be got attested with official seal by any one of the following officials: (i) Magistrate; (ii) A Gazetted Officer; (iii) Post/Sub‐Postmaster; (iv) President of Village Union; (v) President of the Village Panchayat where there is no Union Board; (vi) Chairman/Secretary/Member of the Municipal/District/Local Board; (vii) Member of Parliament/Legislative Assembly; (viii) Member of C.B.T. Regional Committee of the E.P.F.; (ix) Manager of the Bank where claimant has account; (x) Head of any recognised educational institution or; (xi) Any other official asmay be approved by the Commissioner.

6) Instruction to employers.—While forwarding the claims the employer should ensure that all the information required in the claim furnished correctly and requisites documents are enclosed in support of claim under Employees’ Family Pension Scheme, 1971 the period of break in reckonable service (i.e. period for EPF contribution is not payable should be furnished, if not already intimated through contribution card.

Signature

For Office use only

Dated........................

Official Seal and Registration No. ....................

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FORM 31 Application for Advance From the Fund

[Refer: Instructions] (For office use only)

Dated......................... Official Seal and Registration No. ......................... Amount of advance required (in words)................

Purpose of which advance is required......................... ...................................................................................... Name in full (in block letters).........................

1. Father’s/Husband’s name.................................

2. Name of the factory/establishment in which employed and address ...................................................................

3. Provident Fund Account No. ..........................

4. Monthly basic wages, DA : Basic + DA Total.........................

5. Full postal address of the member to which payment/intimation to be sent..........................................................

6. Mode of remittance

a) In case of advance for purchase of site/house/flat or construction through an ‘agency’ or repayment of

housing loan, indicate i. in whose favour of the cheque is to be drawn and ii. full address.........................

In other cases put a tick against any one of the following:

b) By account payee cheque, through the employer (to the address given against Sl. No. 3) c) By deposit in Bank A/c. No. ......................... located at......................... (Full postal address) d) By money order at my cost to the address given against SI. No. 6.

*I declare that the advance is required to meet the expenses in connection, with my marriage/marriage of my

son/daughter/brother/sister, Shri/Kumari ......................... aged......................... to be celebrated on......................... (Date) at ............. ............ (Address)

I declare that the above particulars are true to the best of my knowledge and I will abide by the conditions

governing the grant of advance under the Scheme, Certificate(s)/document(s) in support of my application is/are furnished /enclosed. Station......................... Signature/left or right hand thumb

Date......................... impression of the member ————— *Delete if the advance applied for is not for marriage.

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Advance stamped receipt

[To be furnished with reference to 7(a) or (b) or (c) above only]

Received a sum of *Rs. ......................... (Rupees.........................) from the Regional Provident Fund

Commissioner/Officer in‐charge of Sub‐regional Office, Employees’ Provident Fund towards the grant of advance from my Employees’ Provident Fund Account maintained by him.

Signature of member

*To be filled by the Employees’ Provident Fund Office

To be furnished by the employer

(During the closure/lock‐out of the factory/establishment by any Gazette Officer or the Chief Executive/Head of a

local authority or MP or MLA or a Member of CBT/Regional Committee, EPF)

Certified that the application has been signed by the member in my presence after he/she had read the

contents/the contents had been explained to him/her by me and that the information given in the application is correct. Required certificate(s) is/ are enclosed.

Date......................... Designation of the signing official with

stamp of the factory /establishment Encls.......................... Signature of employer or an authorized

official of the factory/establishment

For use in Provident Fund Commissioner’s Office

Section......................... Account No. .........................

Authority for payment of advance only Para 68 Passed for payment for Rs. ......................... (Rupees......................... only) Mode of remittance: Refer Sl. No. 7 M.O. Commission, if any Net amount to be paid by MO......................... Clerk Head Clerk Accounts Officer P.I. No. .........................vide payment scroll P.C. to A .O.

For use in cash section Paid by inclusion in Cheque No. .........................dated......................... vide Cash Book (Bank) Account No. 3 ...............debit item No. ......................... Clerk Head Clerk Assistant Commissioner

REMARKS .............................................................................................................................

Instructions

Forms under



A member of the Fund may avail the following non‐refundable advances:The documents to be furnished in support of the application are given in brackets: 1. Purchase of a dwelling site

(From an ’agency’)—Original allotment order. (From an individual)—Original title deed non‐encumbrance certificate. (for verification and return agreement with the seller)

2. Purchase of a dwelling‐house/flat (From an ’agency’)—Original Allotment order. (From an individual)—Original title deed (for verification and return agreement with the seller, non‐encumbrance certificate from an appropriate authority that the house/flat is a new and unveiled one furnishing the number and date of approval of plan, commencement and completion of the house/flat tax bills and receipts.

3. Construction of house (Original title deed) (for verification and return), non‐ encumbrance certificate, estimated cost for construction. Approved plan. Note.—While claiming the second and subsequent instalments the declaration/ certificate as requried by the Commissioner in his letter sanctioning the advance should be submitted along with the application. ‘Agency’ referred to in 1 to 3 above would mean Central/State Government, a Co‐operative Society, an institution, a trust, a local body or a housing finance corporation. In case of transactions through an agency the payment will be made only by Account Payee Cheque, direct to the ‘agency’ concerned].

4. Additions, alteration or improvement to the house owned by member or by spouse (Approval of the

appropriate authority, estimate of the work, original title deed of the house (for verification), non‐encumbrance certificate, a certificate from the appropriate authority specifying the date of completion of the house.)

5. Repayment of (Housing) loan to the State Government Housing Board, Municipal Corporation or a body

similar to Delhi Development Authority A certificate from the lending authority furnishing the details of loan and outstanding amount. 6. Closure/lock‐out of the factory/establishment, for reasons other than strike

(Furnish the certificate ‘A’ given later)

7. Non‐receipt of wages for 2 months (Furnish the certificate ‘B’ given later)

8. Illness of member/family member (Furnish the certificate ‘C’ given later)

9. Marriage of self/son/daughter/sister/brother.

10. Post‐matriculation education of son/daughter (Certificate from the Institution regarding the course of study and anticipated expenditure)

11. Damage to the property due to natural calamity (Flood/riot/earthquake) (Furnish the certificate ‘D’ given

later)

12. Affected by cut in electricity (Furnish the certificate ‘E’ given later)

13. Purchase of equipment for physically handicapped members (Furnish the certificate ’F’ given later) Note.—

Forms under



1. Such other document, certificate, etc. as may be required by the sanctioning authority are also required to be furnished through the establishment.

2. In case no intimation is received within a month please write to the RPFC/Officer‐in‐charge of sub‐regional office, through the establishment.

Certificate—A (Refer instruction Sl. No. 6)

Certified that no compensation was paid to the member Sri/Smt. ......................... for the period of lock‐out/closure.

Signature of employer /authorised official with date and seal

Certificate—B (Refer instruction Sl. No. 7) Certified that member Sri/Smt. ......................... has/had been granted leave for a period of......................... from......................... to.........................

i. The ESI facilities/cash benefits are not actually available to the member/themember has ceased to be eligible for cash benefits under ES1‐‐Certificate from ESI enclosed.

Signature of the employer/authorised officer with date and seal

Certificate—C (Refer instruction Sl. No. 8) Certified that—

i. The memebr Sri/Smt. ....................................has/had been granted leave for a period of....................... from............................ to......................

ii. The ESI facilities/cash benefits are not actually available to the member/the member has ceased to be eligible for cash benefits under ESI certificate from ESI enclosed.

(Signature of the employer/authorised officer with date and seal)

Medical certificate to be issued: (i) in case of major surgical operation or where the hospitalisation for one month or more had or has become necessary—By a doctor of the Government/ESI /private hospital; (ii) in case of treatment of TB, leprosy, paralysis or cancer‐ by a doctor of Government /private hospital/ESI or by a registered medical practitioner; (iii) in case of treatment of heart ailment or mental derangement—By a specialist doctor.

(ii) Certified that Sri /Smt./Kumari......................... S/o., W/o., D/o. ........................

i. is suffering from TB/leprosy/paralysis/cancer/mental derangement/heart ailment. ii. is suffering from......................... (disease) for which a major surgical

operation/and hospitalisation for a period of......................... days from......................... to......................... had or has become necessary.

iii. is suffering from......................... and hospitalisation for a period of days from......................... to......................... had or has become necessary. Signature of the Doctor with date and seal —————

Forms under



* Delete whichever is not applicable.

Certificate—D (Refer instruction Sl. No. 11)

Certified that the movable/immovable property of Sri/Smt. ......................... viz..........................situated at......................... has been damaged due to......................... on (date)......................... The estimated loss of property due to......................... calamity is valued at Rs. ......................... The State Government has declared that the calamity has effected the general public in the area in which the property of the member is/ was located vide Notification/Press release No. ................ and date.

Signature of employer/ revenue official/ Gazetted officer/MLA/MP/

Member of CBT/Regional Committee with seal and date

Certificate—E (Refer instructions SI. No. 12)

Certified that the fall in wages amounting to 25% more than 25% of the wages in respect of Sri/Smt. ......................... due to power cut.

Signature of the employer/ authorised official with date and seal

Certificate—F (Refer instructions Sl. No. 13)

Medical certificate from a competent medical practitioner

Certified that Sri/Smt./Kum. ......................... S/o/ W/o/ D/o ......................... is physically handicapped, viz. ......................... (Nature of handicap) and requires the equipment, viz. ......................... costing about Rs. ......................... to minimise the hardship on account of handicap.

Signature of the doctor with date and seal

—————

Forms under

THE EMPLOYEES’ STATE INSURANCE (GENERAL) REGULATIONS, 1950

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ K 1

Forms under


Forms under



INDEX FORM 01 Employer’s Registration Form

FORM 01(A) Form of Annual Information of Factory/Establishment Covered under ESI Act

FORM 1 Declaration Form

FORM IA Family Declaration Form

FORM 2 Addition/Deletion in Family Declaration Form

FORM 3 Return of Declaration Form

FORM 4 Identity Card

FORM 4A Family Identity Card

FORM 5 Return of Contributions

FORM 5A Statement of Advance Contributions Made for the Contribution Period

FORM 6 Register of Employees

FORM 7 First/Intermediate/Final Certificate

FORM 8 Special Intermediate Certificate

FORM 9 Claim for Sickness/T.D.B./Maternity Benefit for Sickness

FORM 10 Abstention Verification in Respect of Sickness Benefit/Temporary Disablement Benefit/Maternity Benefit

FORM 11 Accident Book

FORM 12 Accident Report From Employer

FORM 13 Death Certificate

FORM 14 Claim for Permanent Disablement Benefit

FORM 15 Claim Form for Dependants’ Benefit

FORM 16 Claim for Periodical Payments of Dependant’s Benefit

FORM 17 Certificate/Notice of Pregnancy

FORM 18 Certificate of Expected Confinement/ Confinement/Miscarriage/Maternity Benefit

Forms under



FORM 19 Claim for Maternity Benefit and Notice of Work

FORM 20 Claim for Maternity Benefit After the Death

of an Insured Woman Leaving Behind the Child

FORM 21 Death Certificate in Case of Confinement of Claiming Maternity Benefit

FORM 22 Funeral Expenses Claim Form

FORM 23 Life Certificate for Permanent Disablement Benefit

FORM 24 Declaration and Certificate for Dependants’ Benefit

Forms under



FORM 01 Employer’s Registration Form

[Regulation 10‐B ]

*Employer’s Code No.

1. Name of the Factory/Establishment

……………………………………………….

2. Complete Postal address of the Factory/Establishment

………………………………………………. …………………PIN……………………….

3. a) Telephone No., if any b) Fax No., if any c) E‐mail address, if any

………………………………………………. ………………………………………………. ……………………………………………….

4. Location of Factory/Establishment a. State b. District c. Municipality/Ward d. Name of Town/Revenue village e. Police station f. Revenue Demarcation/Hudbast No.

………………………………………………. ………………………………………………. ………………………………………………. ………………………………………………. ………………………………………………. ……………………………………………….

5. a. Whether the building/premises of Factory/Estt.

is owned or hired.

b. If hired or there is a change in the name of Unit/ownership, please indicate— i. ESI code number, if covered earlier ii. Date from which earlier Factory/ Estt.

closed down. iii. Terms and conditions under which

property acquired/taken on lease (enclose copy of agreement/relevant deed)

…………………………………………….. ………………………………………………. ………………………………………………. ……………………………………………….

6. Details of Bank A/c.: a) Account No................................ b) Account No................................ c) Account No................................

(b) Name of Bank and Branch: (i) ................................................................. (ii) ................................................................ (iii) ...............................................................

7. (a) Income Tax PAN/GIR No. (b) (b) Income Tax Ward/Circle/Area

………………………………………………. ……………………………………………….

8. Exact nature of work/business carried on

……………………………………………….

9. Date of commencement of Factory/ Establishment

……………………………………………….

Forms under



10. a. Whether registered under Factories/Shop & Estt./

Other Act (Please Specify) : b. Factory licence No./Trade licence No./Catering

Estt. licence No./Shop, Estt. Registration No./Licence No. under Cinematography Act etc.

c. Please give whichever is applicable i. Commercial Tax No. ii. State Sales Tax No. iii. Central Sales Tax No.

iv. Any other Tax No. d. Maximum no. of persons that can be employed

on any one day, as per Licence :

………………………………………………. License No. Date Licensing Authority No. Date Issung Authority

i. ii. iii. iv.

…………………………………………………………………...

11. a) Whether power is used for manufacturing

process as per section 2(K) of the Factories Act. If so, since when :

b) In case of factory whether Licence issued underSection 2(m)(i) or 2(m)(ii) of the Factories Act, 1948

c) Power connection No.

……………………………………………………………….. ………………………………………………………………. …………………………………………………………………. No. Sanctioned Power Load Issuing Authority

12. a. Whether it is Public or Private Ltd.

Company/Partnership/Proprietor‐ship/Co‐operative Society/Owner‐ship (attach copy of Memorandum & Articles of Association/ Partnership Deed/Resolution). :

b. Give name, present and permanent : residential address of present Pro‐ prietor/Managing Directors, Dire‐ ctor/Managing Partners, Partners/ Secretary of the Co‐operative Society.

………………………………………………………………. Name Designation Address

i. ii. iii. iv. v. vi. vii.

13. Address(es) of the Registered Office/ Head Office/Branch Office/Sales office /Administrative Office/other offices if any, with no. of employees attached with each such office and person responsible for the office.

Address as on date

No. of employee

Phone No. / Fax No.

Function Person responsible for day ‐to ‐day‐ functioning of office

14. a. (a)Whether any work/business carried out

throught contractor/immediate employer : b. If yes, give nature of such work/ business

(Give details on separate sheet , if required) ……………………………………………………………………. ……………………………………………………………………..

15. EPF Code No. (If covered under EPF Act) No. Issuing Authority

16. Total number of employees employed for wages directly and through immediate employers on the date of application. (whether manual/clerical/supervisor, connected with the administration or purchase of raw

Forms under



materials or distribution or sale of product/service, whether permanent or temporary)

As on date Total No. of employees No. of employees drawing wages Rs. 7500 or less

Male Female Total Male Female Total Employed directly by the Principal Employer

Through Immediate employer/Contractor

Total

17. Total wages paid in the preceding month.

Total wages

Wages paid to employees drawing wages Rs. 7500 or less

To employees employed directly by the Principal employer

To employees employed through Immediate employer/Contractor

18. Give first date since when 10/20** : ......................................................................... or more coverable employees under ESI Act were employed for wages

I hereby declare that the statement given above is correct to the best of my knowledge and belief. I also undertake to intimate changes, if any, promptly to the Regional Office/ Sub‐Regional Office, ESI Corporation as soon as such changes take place. Date.......................... Name & Signature............................. Place......................... Designation with seal........................

(Should be signed by principal employer under section 2(17) of ESI Act)

* Please mention the Employer’s Code No., if previously allotted in case the factory/ establishment was covered under the ESI Act.

** Score out whichever is not applicable. In case of factory/an establishment using power in the manufacturing process the number applicable is 10 persons or more. In the case of a factory not using power or an establishment engaged in manufacturing process without using power or any other establishment, the number applicable is 20 or more person.

Instructions

Note 1.—Please enclose photocopy of the following deeds/agreements/documents/ certificate:—

a. Registration Certificate/Licence issued under the Shops and Establishment Act or Factories Act. b. Latest Rent Bill of the premises you are occupying indicating the capacity in which the premises is occupied,

if applicable. c. Latest building Tax/Property Tax receipt (Zerox).

Forms under



d. Memorandum and Articles of Association/Partnership Deed/Trust Deed. e. Zerox Copy of certificate of commencement of production and/or Registration No. of CST/ST. Note 2.—“Power” shall have the meaning assigned to it in the Factories Act, 1948 which is as under: “power” means electrical energy, or any other form of energy which is mechanically transmitted and is not generated by human or animal agency.

Note 3.—Manufacturing process as defined in section 2(k) in Factories Act is as under: “Manufacturing process” means any process for—

i. making, altering, repairing, ornamenting, finishing, packing, oiling, washing, cleaning, breaking up, demolishing, or otherwise treating or adapting any article or substance with a view to its use, sale, transport, delivery or disposal;

ii. pumping oil, water, sewage or any other substance; iii. generating, transforming or transmitting power;

iv. composing types for printing, printing by letter press, lithography photogravure or other similar process or book binding;

v. constructing, reconstructing, repairing, refitting, finishing or breaking up ships or vessels; vi. preserving or storing any article in cold storage.

Note 4.—“Immediate employer” in relation to employees employed by or through him, means a person who has undertaken the execution, on the premises of the factory or an establishment to which this Act applies or under the supervision of the principal employer or his agent, of the whole or any part of any work which is ordinarily part of the work of the factory or establishment of the principal employer or is preliminary to the work carried on in, or incidental to the purpose of, any such factory or establishment and includes a person by whom the services of an employee who has entered into a contract of service with him are temporarily lent or let on hire to the principal employer and includes a contractors. Note 5.—“Principal Employer” means—

a. in a factory, the owner or occupier of the factory and includes the managing agent of such owner or occupier, the legal representative of a deceased owner or occupier and where a person has been named as the manager of the factory under the Factories Act, 1948, the person so named;

b. in any establishment under the control of any department of any Government, in India the authority appointed by such Government in this behalf or where no authority is so appointed, the head of the Departments;

c. in any other establishment, any person responsible for the supervision and control of the establishment. Note 6.—“Occupier” of a factory/establishment means the person who has ultimate control over the affairs of the

factory/establishment and when the said affairs are entrusted to a managing agent shall be the Occupier of the factory/establishment. Note 7.—“Employees” means any person employed for wages in or in connection with the work of a factory or an

establishment to which this Act applies and—

i. who is directly employed by the principal employer on any work of, or incidental or preliminary to or connected with the work of, the factory or establishment whether such work is done by the employee in the factory or elsewhere; or

ii. who is employed by or through an immediate employer on the premises of the factory or establishment or under the supervision of the principal employer or his agent on work which is ordinarily part of the work of the factory or establishment or which is preliminary to be carried on in or incidental to the purpose of the factory or establishment; or

iii. whose services are temporarily lent or let on hire to the principal employer by the person with whom the person whose services are so lent or let on hire has entered into a contact of service,

Forms under



and includes any person employed for wages on any work connected with the administration of the factory or establishment or any part, department or branch thereof with the purchase of raw materials for, or the distribution or sale of the products of, the factory or establishment; (or any person engaged as an apprentice, not being an apprentice engaged under the Apprentices Act, 1961 (52 of 1961), or under the standing orders of the establishment; but does not include)—

a. Any member of the Indian Naval, Military or Air Force; or b. Any person so employed whose wages excluding remuneration for overtime work exceeds such wages as

may be prescribed by the Central Government, a month:

Provided that an employee whose wages excluding remuneration for over time work exceeds such wages as may be prescribed by the Central Government, a month at any time after and not before the beginning of the contribution period, shall continue to be an employee until the end of that period.

Note 8.—“Wages” means all remuneration paid or payable in cash to an employee, if the terms of the contract of

employment, express or implied, were fulfilled and includes any payment to an employee in respect of any period of authorised leave, lock‐out, strike which is not illegal or lay off and other additional remuneration, if any, paid at intervals not exceeding two months, but does not include—

a. any contribution paid by the employer to any pension fund or provident fund, or under this Act; b. any travelling allowance or the value of any travelling concession; c. any sum paid to the person employed to defray special expenses entailed on him by the nature of his

employment; or d. any gratuity payable on discharge.]

Forms under



FORM 01 (A) Form of Annual Information of Factory/Establishment Covered under ESI act

(See Regulation 10 –C) Employer’s Code No.

1. Name of the factory/establishment: ………………………………………….. 2. Complete postal address of the : ………………………………………….

Factory/Establishment …………………PIN…………………….. …………………………………………………

3. (a) Telephone No., if any (b) Fax No., if any………………………..

(c ) E‐mail address, if any……………….

4. Location of factory / establishment: ………………………………. (a) State……………….. (b) District………………….. (c) Municipality/Ward…………………….. (d) Name of Town/Revenue Village (Taluk/Tahsil)……………. (e) Police Station……………………… (f) Revenue Demarcation/Hudbast No…………> 5. (a) Details of Bank A/c: (b) Name of Bank and Branch

(a) Account No…………….. (i) ……………………………. (b) Account No……………… (ii) ………………………….. (c) Account No………………… (iii) ………………………….

6. (a) Income tax PAN/GIR No. :…………………………………..

(b) Income Tax Ward/Circle/Area : ……………………………………

7. (a) In case of factory whether :……………………………………………….

License issued under Section

2(m)(i) or 2(m)(ii) of the Factories Act, 1948

(b) Power Connection No. No. Sanctioned power load issuing Authority

8. (a) Whether it is Public or private Ltd. :………………………………………. Company/ Partnership/Proprietorship Cooperative Society/ Ownership (Attach copy of memorandum and Articles of Association / Partnership Deed /Resolution

Forms under


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ K 1 0

(b)

Give name, Present and Permanent residential Address of present proprietor Managing Directors, Director/

Managing Partners, Partners/ Secretary of the Co‐operative

Society

Name

(i) (ii) (iii) (iv) (v) (vi) (vii) (viii)

Designation Address

9.

Address(es) of the Registered Office/ Head office / Branch Office/sales office administrative office / other offices, if any with Number of employees attached with each such office and person of the office

responsible for the office

Address as on date

No. of employees

Phone No. / Fax No.

Function Person responsible for day‐to‐day functioning of the office

(Give details on a separate sheet, if required)

10. (a) Whether any work/business : ……………………………………………. Carried out through contractor/ Immediate employee

(b) If yes, give nature of such work/business: …………………………………

I hereby declare that the statement given above is correct to the best of my knowledge and belief. I also undertake to intimate changes, if any, promptly to the Regional Office/ Sub‐Regional office, ESI Corporation as soon as such changes take place.

Date Name and Signature……………

Place designation with seal…………….

[Should be signed by principal employer under Section 2 (17) of ESI act]

Forms under



FORM 1 Declaration Form (Regulations 11 and 12)

To be filled in by the employee after reading instructions overleaf. Two Postcard Size photographs are to be attached with this from.

This from is free of cost.

(A) INSURED PERSONʹS PARTICULARS

1. Insurance No.

2. Name (In block letters)

3. Fatherʹs/Husbandʹs Name

4. Date of Birth

D M Y 5. Marital Status M/U/W

6. Sex M/F

7. Present Address ..................................................... ..................................................... ..................................................... ..................................................... Pin Code e‐mail address

8. Permanent Address............................................................................. .................................................................................................................. …………………………………………………………………………… ........................................................................................................ Pin Code e‐mail address

Branch Office Dispensary

(B) EMPLOYERʹS PARTICULARS

9. Employerʹs Code No.

10. Date of Appointment Day Month Year

11. Name & Address of the Employer .................................................................................................... .................................................................................................... ....................................................................................................

12. In case of any previous employment please fill up the details as under:

(a) Previous Ins. No.

Forms under



(b) Employerʹs Code No.

(c) Name & address of the Employer Telephone No./ e‐mail address

(c) Details of Nominee u/s 71 of the ESI Act, 1948/Rule 56(2) of the ESI (Central) Rules, 1950 for payment of cash benefit in the event of death.

Name Relationship Address

I hereby declare that the particulars given by me are correct to the best of my knowledge and belief. I undertake to intimate the Corporation any changes in the membership of my family within 15 days of such change.

Counter‐signature by the employer Signature/T.I. of IP Signature with seal (D) FAMILY PARTICULARS OF INSURED PERSON Sl. No.

Name Date of Birth/ Age as on date of filling from

Relationship with the Employee

Whether residing with him/her?

If ʹNoʹ, state place of Residence

1. Yes No Town State

2.

3.

4.

5.

6.

7.

8.

..................................................................................................................................................................

Forms under



ESI Corporation Temporary Identity Card (Valid for 3 months from the date of appointment) Name

Ins. No. Date of appointment

Branch Office

Dispensary

Employerʹs Code No. & Address

Validity. Dated Signature/T.I of I.P Signature of B.M. with seal

INSTRUCTIONS

1. Submission of Form 1 is governed by regulations 11 and 12 of the ESI (General) Regulations, 1950. 2. ʺFamilyʺ means all or any of the following relatives of an Insured Person namely:—

(i) a spouse; (ii) a minor legitimate or adopted child dependent upon the I.P.; (iii) a child who is wholly dependent on the earnings of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) an unmarried daughter; (iv) a child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependant on the earnings of the I.P. so long as the infirmity continues: (v) dependant parents [Please see section 2, clause (11) of the ESI Act, 1948 for details].

3. Identity Card is Non‐transferable. 4. Loss of Identity Card be reported to Employer/Branch Manager immediately. 5. Submission of false information attracts penal action under section 84 of the ESI Act, 1948. 6. This form duly filled in must reach the concerned Branch Officer within 10 days of appointment of an

employee. Delay attracts penal action under section 85 of the Act, against employer. 7. As an Insured Person you and your dependent family members are entitled to full medical care. The other

benefits in cash include (1) Sickness Benefit (2) Temporary Disablement Benefit (3) Permanent Disablement Benefit (4) Dependents Benefit and (5) Maternity Benefit (in case of women employees) subject to fulfillment of contributory conditions.

8. For more details please visit website of ESIC at WWW.esic.org.in or contact Regional Office or Branch Office.

Space for photograph

For Branch Office use only

1. Date of Allotment of Ins. No. …………………………………………..

2. Date of Issue of TIC …………………………………………………..

3. Name/No. of Disp. …………………………………………………….

4. Whether reciprocal Medical arrangements involved? If yes, please indicate:………………………………………

Signature of Branch Manager

Forms under



Sl. No.

Name Date of Birth/ Age as on date of

filling from

Relationship with the Employee

Whether residing with him/her?

If ʹNoʹ, State place of Residence

1. Yes No Town State

2.

3.

4.

5.

6.

7.

8.

Forms under



FORM I –A Family Declaration Form

(Regulation 15‐A)

Name of the insured person………………………………………………………

Insurance Number…………………………………………………………………..

Serial No. Name Date of Birth Relationship with insured persons

Whether residing with him/her or not

I hereby declare that the particulars above have been given by me and are true to the best of my knowledge and belief. I also undertake to intimate to the Corporation any changes in the membership of my family within 15 days of such changes having occurred.

Date …………………….. Signature or thumb impression

of the insured person

Countersigned……………

Date…………………………

Designation………………………….

Name, address and

Code No. of Employer………………………………………………………………………………………….

Forms under



FORM 2 Addition/Deletion in Family Declaration Form

EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 15B)

Name of the Insured Person ............................... Insurance No.

I declare that the person/persons whose particulars are given below has/have now become/ceased to be members of my family.*

Sl No. Name Date of

birth Reasons for change and date

Relationship with the insured person

Whether residing with him/her not state

If no, where residing

Name of IMP/ Disp. attached

Yes No Dist. State


Necessary changes may kindly be made in my Declaration Form submitted earlier. Passport size photographs of the members who are added to family is/are enclosed. Place................................. . .............................................................................. Date.................................. Signature/thumb‐impression of the employee

Name in Block Letters.........................................

Note: ”Family” means all or any of the following relatives of an insured person, namely:— (i) a spouse; (ii) a minor legitimate or adopted child dependent upon the I.P.; (iii) a child who is wholly dependent on the earning of the I.P. and who is (a) receiving education, till he or she attains the age of 21 years (b) an unmarried daughter; (iv) a child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependent on the earnings of the I.P. so long as the infirmity continues; (v) dependant parents (Please see section 2, clause (11) of the ESI Act, 1948 for details).

* Please submit duly attested copy of the Birth/Death Certificate.]

Particulars of the Employer: Name.......................................... Address...................................... ....................................................

Code No.....................................

Counter-signature of the employer

………………………………………… Designation with Rubber Stamp

Forms under



FORM 3 (Regulation 14)

Return of Declaration Forms

Name and address of the Factory or Establishment......................................................... Employer’s Code Number

I send herewith the Declaration Forms in respect of the employees mentioned below. I hereby declare that every

person employed as an employee within the meaning of section 2(9) of the Employees’ State Insurance Act, 1948,

on.................in this factory or establishment and in receipt of a remuneration not exceeding 1[Rs. 10,000] per month has been included in this list (excepting only those in respect of whom declarations have been sent to the Corporation in the past).

Place.............................. Signature............................................. Date.............................. Designation.........................................

Serial No.

Name of the employee

Distinguishing No. with the employer,

if any

Father’s or Husband’s name

Insurance No. allotted by the corporation (to be entered at the Appropriate Office)

(1) (2) (3) (4) (5)

Signature................................ Designation............................

Enclosures: ‐ Declaration Forms ________________ Continuation sheets ______________

Forms under



FORM 4 (Regulations 17)

Identity Card Insurance No.

Name ............................. Sex......................... Son of/daughter of/wife of ........................ Year of birth ................................................... Address .......................................................... ......................................................................... Dispensary ..................................................... Local Office ....................................................

Identification marks

Photograph of the insured person

Employment changes Date Code No. Date Code No

Prepared by ................................................... Signature or thumb‐impression of the employee

Forms under



FORM 4‐A Family Identity Card

Insurance No.

Name of insured person………………………………..

Sex………………………………………………………………..

Son of / Daughter of /Wife of……………………..

Address……………………………………………………..

Dispensary………………………………………………….

Particulars of member of family

Serial No. Name Dare of birth Relationship with the insured person

Identification marks

1

2

3

4

5

6

Signature of thumb‐ Impression of the insured person

Prepared by

Signature of Inspector or Authorized Official

Forms under



FORM 5 (Regulation 26)

Due date for submission— Name of Branch Office...................... Employer’s Code No. ....................

Return of Contributions EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 26) Name and address of the factory or establishment:.................................................................. Particulars of the principal employer(s):

a) Name:.................................................................................................................................. b) Designation:........................................................................................................................ c) Residential address:...........................................................................................................

Contribution Period from.......................................... to......................................... I furnish below the details of the Employer’s and Employee’s share of contributions 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.

Employee’s Share........................................ Employer’s Share......................................... Total contribution........................................

Details of Challans:

Sl. No. Month Date of Challan Amount Name of the Bank and Branch

1. 2. 3. 4. 5. 6.

Total amount paid: Rs....................................

I declare that

(w). All the Records and Registers have been maintained as per provisions contained in ESI Act, rules and regulations framed therein.

(x). During the period of return…. No. of Declaration forms have been submitted.

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(y). During the above period …No. of TICs have been received.

(z) During the above period…..No. of PICs have been received.

(aa) During the above period….No. of PICs have been distributed amongst the eligible IPs.

(bb) During the above period………. accidents have been reported to the concerned branch Office.

(cc) During the period…No of employees directly employed by us been covered and a total wages of Rs………….have been paid to such employees.

(dd) During the period…………No. of employees directly employed by us have not been covered and a total wages of Rs…………. have been paid to such employees.

(ee) During the period ……………No of employees employed through immediate employer have been covered and a total wages of Rs…….. have been paid to such employees.

(ff) During the period…………………….No. of employees employed through immediate employer have not been covered and at total wages of Rs……………have been paid to such employees.

(gg) Following components of wages have been taken into consideration for the purpose of payment of contribution—

1.

2.

3.

4.

5.

(i) Following components of wages not been taken into consideration for the purpose of payment of contribution‐

1.

2.

3.

4.

5.

The abovementioned information is based on records and any information if found incorrect will render me liable for prosecutions under provisions of ESI Act and action for recovery of contribution due along with interest and damages as per provisions of the ESI Act.

Place…………. Signature and Designation of the Employer

Date….. (with Rubber Stamp)

Forms under



CERTICATE BY CHARTERED ACCOUNTANT

(To be submitted in case of employers employing 40 or more employees)

Certified that I have verified the above return from the Records and Registers of M.s………..and found it to be correct.

Signature and seal of the Charted

Accounted with Membership No.

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 and 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. v. No over‐writing shall be made. Any corrections, if made, should be signed by the employer. vi. Every page of this Return should bear full signature and rubber stamp of the employer. vii. Daily wages in column 7 of the Return shall be calculated by dividing figures in column 5 by figures in

column 4 to two decimal places.

For *CP ending 31st March, due date is 12th May For CP ending 30th September, due date is 11th November


Employer’s Name and Address.....................................................................................................

Employer’s Code No................................................ Period From................to...............

Sl. No.

Insurance Number

Name of insured person

No. of days for which wages paid

Total amount of wages paid (Rs.)

Employee’s contribution deducted

(Rs.)

Average Daily wages (Rs.)

Whether still continues working

Remarks*

(1) (2) (3) (4) (5) (6) (7) (8) (9) Total

* Date of appointment and leaving the job may be given in remarks column.

Signature of the Employer

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(FOR OFFICAL 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.

Counter‐signature...........................

U.D.C. Head Clerk Branch Officer]

Forms under



FORM 5 –A

(Regulation 31‐ Second proviso)

Statement of Advance Payment of Contributions Made for the Contribution Period Ended…………………

Total contribution amounting to Rs…………………………comprising of ……………………….Rs……………as employer’s share and Rs……………………..as employees’ share paid under

S.No Details of Advance payment

Amount Details of actual contribution paid

Amount Balance

(1) (2) (3) (4) (5) (6)

1 Opening balance

2 Challan dated.. ……… *April/October …………….. ……….

3 Challan dated….. ………….. *May/November ………………. …………….

4 Challan dated…. ……………. *June/December ………………… …………..

5 Challan Dated… ……………. *July/January ………………. ………………

6 Challan dated…. ………. *August/February ………………. ………………..

7 Challan dated… ……………… *September/March …………….. ………………..

Total (i) ……………….. Total (ii) due for contribution period

Total amount paid in Advance

Balance

Total (ii) should not be less total (i) at any time

*Strike out which is not applicable

Place………………………… Signature…………………………………………………

Date…………………………. Designation……………………………………………..

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FORM 6 Register of Employees

EMPLOYEES’ STATE INSURANCE CORPORATION [Regulation 32]

Contribution period: From........................................... to................................ Month…………………..

Sl No.

Insurance No.

Name of the insured person

Name of dispensary to which attached

Occupation

Deptt. And shift if any

If appointed or left service during the contribution period, date of appointment/ leaving service

No. of days for which wages paid or payable

Total amount of wages paid or payable

Employee’s share of contribution

1 2 3 3(a) 4 5 6 7 8 9

Total………………………….. Employer’s share……………………….. Grand Total…………………………… Paid on……………………………….

Month Month

No. of days for which wages paid/ payable

Total amount of wages paid/ payable (Rs)

Employee’s share of contribution (Rs)




10 11 12 13 14 15


Forms under



Month Month







16 17 18 19 20 21


Month Total No. of days

for which wages paid/ payable in contribution period (Rs)

Total amount of wages paid/ payable (Rs) in contribution period (Rs)

Total Employee’s share of contribution in contribution period (Rs)

Daily Wages (25‐26)




22 23 24 25 26 27 28

Total………………………….. Employer’s share……………………….. Grand Total…………………………… Paid on…………… Note: The figures in Columns 7 to 24 shall be in respect of wage periods ending in a particular calendar month.]

Forms under



FORM 7 (Deposit this certificate within 3 days with the appropriate Branch office

to avoid possible loss of benefit under regulation 64)

First/Intermediate/Final Certificate (Regulations 57, 58, 59 and 89B)


Book No.............. ..................................................................

Serial No............. Stamp of Dispensary Signature or thumb‐impression of I.P. Date of First Certificate of spell of Employer’s Code No............................. Sickness or Disablement.................................... Branch Office.........................................

Name.......................................s/w/d/of..............................Insurance No................................... Certified that I have examined you today and that in my opinion:— Any other remarks by the

Medical Officer

............................................................

............................................................

............................................................

Attestation by Med. Officer

i. *You now need medical treatment, attendance and abstention from work on medical grounds by reason of (diagnosis)............................................

ii. *You have continued to need medical treatment, attendance and abstention from work on medical grounds upto and including this day by reason of (diagnosis)..................................................

iii. *In my opinion you will be fit to resume work tomorrow/on.............................................................

Note: The date of fitness must in no case bet later than the third day after the date of the examination in case of First and Final Certificate. Date..................... Signature..........................

Insurance Medical Officer Rubber stamp

Name in Block Letters.........................................

* Strike out whichever is not applicable IMPORTANT:

1. Any person who makes false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment up to 6 months or fine up to Rs. 2000 or both.

2. This form should be completed and submitted without delay to the appropriate Branch Office to escape penal deduction of benefit under regulation 64 read with regulation 99 of ESI General Regulation, 1950.

3. Insured person must sign, with date, the claim form to avoid delay and inconvenience]

Forms under



FORM 8 (Confidential)

(Deposit this certificate within 3 days with the appropriate Branch office to avoid possible loss of benefit under regulation 64)

Special Intermediate Certificate EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulations 61 and 89B)

Book No.............. ..................................................................

Serial No............. Stamp of Dispensary Signature or thumb‐impression of I.P. Date of First Certificate of spell of Employer’s Code No............................. Sickness or Disablement....................................

Branch Office.........................................

To.......................................s/w/d/of...................................Insurance No...................................

Any other remarks by the Medical Officer ……………………………………………… ………………………………………………. ……………………………………………... Attestation by Medical Officer

Certified that I have examined you ……………….. today and that in my opinion you have continued to need medical treatment and have remained incapable upto and including this day by reason of……………. I further certify that by judging your present condition it is found that your sickness is of such a character that it will be unnecessary to see you for the purpose of treatment more frequently than once in .................. weeks, and you will require medical treatment will remain incapable to work at least up to end of ................... weeks form this date............. I propose to issue certificates in this form at the interval stated above, so long as your condition does not require more frequent attendance. In my opinion you should now/need not be referred to a Medical Board to determine if you are permanently disabled.

Date..................... Signature.......................... Insurance Medical Officer with rubber stamp Name in Block letters]

Forms under



FORM 9 Claim for Sickness/T.D.B./Maternity Benefit for Sickness

(EMPLOYEES’ STATE INSURANCE CORPORATION

Regulations 63 and 89B)

I……………….. s/w/d of………………………………. Insurance No. hereby claim cash benefit for period overleaf and state.

i. *That because of sickness/temporary disablement/sickness due to pregnancy/confinement/premature birth of child/miscarriage, I have not been at work since ............................

ii. *I no longer claim to be sick/temporary disabled/sick due to pregnancy/confinement/premature birth of child/miscarriage from ................ and I shall/did not take up any work for remuneration before that date.

iii. *I have not been in receipt of any wages for the days of leave/holiday(s).

iv. *I was not on strike during the period of certified abstention on account of sickness/temporary disablement i.e. from .......................... to .......................... for which the benefit is claimed.

I desire payment in *cash at Branch Office/By Money Order.

Signature or T.I. of claimant

Name in Block Letters.....................................

Address..........................................................

.......................................................................

Notes.—

1. Any person who makes a false statement or representation for the purpose of obtaining benefit whether for himself/some other person shall be punishable with imprisonment up to 6 months or fine up to Rs. 2000 or both.

2. This form should be completed and submitted without delay to the appropriate Branch Office.

3. A final certificate must be obtained before resuming work

* Strike out if not applicable]

Forms under



FORM 10 Confidential

Abstention Verification in Respect of Sickness Benefit/ Temporary Disablement Benefit/Maternity Benefit

EMPPLOYEES’ STATE INSURANCE CORPORATION

[Regulation 52A]

From:

The Manager

............Branch Office,

E.S.I., Corporation,

To

M/s...........................................................................

...................................................................................

Subject:—Verification of abstention from work in respect of Sh./Smt./ Km...................................................... Ins. No.......................... Department..................................

Dear Sir(s)

The above named employee of your factory has submitted a certificate of incapacity for the period from........................ to.......................... and has declared that he/she has not worked on any day during this period.

He/she has further declared that he/she has not received wages as defined under section 2(22) of ESI Act, 1948 for any leave/holiday/weekly off/lay off and strike in respect of any day during the above period and that he/she was not on strike on any day during the above period.

I shall be grateful if you confirm the exact position, in this regard, on the Form, appended within 10 days of the receipt of this Form.

Yours faithfully,

(Manager)

...........................Branch office

CONFIDENTIAL

REPLY TO BE FURNISHED BY THE EMPLOYER IN RESPECT OF FORM NO. 10

Name of the Insured Person/Insured Woman..........................................

Insurance No...........................................

Returned with the remarks that the employee in question has not worked on any day during the period from..................... to.....................or* that he/she has worked on ......................................... during the period from........................... to.....................

Forms under



1. It is further confirmed that—

a. He/she remained on leave with wages for the period from........................ to.....................

b. He/she remained on holidays with wages from............... to.....................

c. He/she was on weekly off with wages from.......................................to……………….

d. He/she was on lay‐off with wages from............... to.....................

e. He/she was on strike from............... to.....................

2. In case, the IP/IW is paid any wages for any of the days falling during the above‐ mentioned period subsequently, the same will be notified to you in due course.

3. The day proceeding the first day of absence was*/was not a holiday for the Insured Person/Insured Woman.

Date................... Signature...........................................

Name in block letters and Designation........................... ................................................................... Code No.....................................................

* Strike out which is not applicable]

Forms under



FORM 11 Accident Book

EMPLOYEES’ STATE INSURANCE CORPORATION (Regulation 66)

S. No.

Date of notice

Time of notice

Name and address of

Sex Age Insurance No.

Shift, Department and occupation

Details of injury

injured person

of the employee Cause Nature Date Time place

1 2 3 4 5 6 7 8 9 10 11 12 13

What exactly was the injured person doing at the time of accident.

Name, Occupation, address & signature or the thumb‐impression of the person(s) giving

notice.

Signature and designation of the person who makes the entry in the Accident Book.

Name, address and occupation of two witnesses.

Remarks, if any

14 15 16 17 18

Forms under



FORM 12 Accident Report from Employer


1. Name & Address of Factory/ Establishment & Telephone No.

2. Nature of Industry or business

3. Employer’s Code No.

4. Branch Office

5. Name and address of the injured person

6. Sex & Age

7. Occupation

8. Insurance No.

9. Department

10. Shift/hrs. of work on the date of accident

11. Hour at which he started work on day of accident

12. Date and hour of accident

13. Exact place of accident

14. Nature and extent of injury (e.g. fatal, loss of finger, fracture of leg, scald etc.)

15. Location of injury (right leg, left hand or left eye etc.

16. Address of premises where accident happened

17. Date of death in case the injured person dies

18. In case the accident happened while meeting an emergency, please state:—

i. Its nature ii. whether the injured person at the time of accident was employed for the purpose of his employer’s trade or business in or about the premises at which the accident took place—

19. Dispensary/IMP allotted to injured person

20. Dr. or Dispensary o Hospital from where injured person received or is receiving treatment.

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21. Name and Address of Witness: 1. .. 2. ..

Yes No 22. Whether wages in full or part are payable to him for the day of

accident.

23. Whether the injured person was an employee under section 2(9) of the Act on the day of accident.

24. Whether contribution was payable by him for the day on which accident occurred.

25. Cause of accident— a. State exactly what the injured person was doing at the time

of accident i.e Brief description of how the accident occurred ...........................................................................................................

b. Was the injured person, at the time of accident, acting in contravention of—

1. the provision of any law applicable to him......................... 2. any orders given by or on behalf of his employer..................... 3. acting without instruction from his employer..........................

In case reply to b (1), (2) or (3) is YES, state whether the act was done for the purpose of and in connection with the employer’s trade or business. In case the accident happened while TRAVELLING in the employer’s transport, state whether the injured person was travelling:—

1. as a passenger to or from his place of work. 2. with the express or implied permission of his employer. 3. the transport is being operated by or on behalf of the

employer or some other person by whom it is provided in pursuance of arrangement made with the employer, and

4. the vehicle was being/not being operated in the ordinary course of public transport service.

Yes No

Note:—Accident Report is required to be submitted to the appropriate Branch Office as well as to Insurance Medical Officer/I.M.P. within 24 hours of the receipt of notice of injury. In case of fatal or serious accidents, it must be submitted immediately to avoid legal penal action under section 85.

I certify that to the best of my knowledge and belief, the above particulars are correct in every respect.

Date of dispatch of report......................

Signature of the Employer............................................ Name in Block letters.................................................... Designation................................................................... (with Stamp)

(For Official Use) Diary No. of accident register & Date............................ Signature of B.M.....................]

Forms under



FORM 13 (In Duplicate)*

Death Certificate (For Dependent’s Benefit or Funeral Expenses)

EMPLOYEES’ STATE INSURANCE CORPORATION (Regulations 79 and 95C)

Book No.............. Stamp of Dispensary Serial No............................. Name of the deceased Insured person........................................................................s/w/d of.................... Insurance No........................ I certify that in my opinion the above‐named deceased Insured Person died on the ..................... day of..................... 20.......... as a result of an injury/due to*................................ I **had been attending him/her for providing medical benefit before his/her death and I attended him/her for the last time on the ..................... day of.................... 20.......

Signature............................

Insurance Medical Officer/I.M.P. Name in block letters and rubber stamp

Any other remarks by the Medical Officer

Dated.....................

* Please indicate the name of the disease. ** May be suitably amended if the Insurance Medical Officer/I.M.P. has not attended the deceased person before

his/her death.]

Forms under



FORM 14 Claim for Permanent Disablement Benefit EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 76A)

I…………………………………………………….. s/d/w of……………………………………………………………………. Insurance No. …………………….having been declared as permanently disabled by the Medical Board/ Medical Appeal Tribunal/ Employees’ Insurance Court, claim Permanent Disablement Benefit accordingly for the period from............... to...............

The amount due may be paid to me by money order/in cash at Branch Office

...................................................... Signature or thumb‐impression of the Claimant

Name in block letters........................... address..................................................

.................................................. Dated..................... Important: Any person who makes a false statement or representation for the purpose of obtaining benefit,

whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend to six months or with a fine up to Rs. 2,000, or with both.]

Forms under



FORM 15 Claim Form for Dependants’ Benefit


Name of the deceased Insured Person ...................................... Ins. No. ...........................S/w/d of ................................................................. Date of Death .............................. Last employed as ........................................................ by...............................................................

I/We the following, being dependants of the above named deceased Insured Person, hereby claim and accordingly apply for dependant’s benefit on account of his/her death:

Name of the dependant

Sex Age or year of birth

Marital status

Relationship with the deceased

Present Address

Name of guardian in case of a minor.

1. 2. 3. 4. 5. 6. 7

I/We declare that the particulars given above are true to the best of my/our knowledge and belief.

I/We also declare that to the best of my/our knowledge and belief, there is no other dependant entitled to claim Dependant’s Benefit in r/o the death of the above‐noted deceased I.P., save and except those mentioned above.

1. ........................... 2. ........................... 3. ........................... 4. ...........................

ATTESTATION** Certified that the declarations, made above are true to the best of my knowledge and belief. * All major dependants should sign individually and the guardian to sign in case of a minor dependant. ** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Departments of Government,

or (ii) a Municipal Commissioner, or (iii) a Workmen’s Compensation Commissioner, or (iv) the Head of the Gram‐Panchayat under the official seal of the Panchayat, or (v) M.L.A./M.P., (vi) Gazetted Officer, or (vii) a member of Local Committee/Regional Board of the ESI Corporation, or (viii) any other authority considered appropriate by the Branch Manager. IMPORTANT: Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months, or with a fine up to Rs. 2000 or with both.]

Signatures*

Name in Block letters and Rubber stamp or seal of the attesting authority

Signature............................. Designation.........................

Forms under



FORM 16 Claim for Periodical Payments of Dependant’s Benefit

EMPLOYEES‘ STATE INSURANCE CORPORATION (Regulation 83A)

Name of the deceased Insured Person....................................... Ins. No............ ......................... I ..........................., being the ............................ of the above‐named Insured Person and also being his/her dependant, do hereby claim Dependant’s Benefit for the period from....................... to................. The amount due may be paid to me by money order

In cash/by cheque at the Branch Office I also declare that— i. * I have not married*/re‐married, so far

(Applicable only in case of a female dependant). ii. * I have not attained the age of 18 years

(Applicable in case of minor male/female dependant). iii. * I am still infirm.

(Applicable only in case of a legitimate/adopted* infirm son or a legitimate/ adopted* unmarried infirm daughter who has attained the 18 yrs. of age. The claim to be accompanied, if required, by a certificate of specified authority).

Date.................... **Signature or thumb‐impression of the claimant.

Present address............................... ............................................................

Name in Block letter of Claimant/Guardian. or ***Signature/thumb‐impression of the Guardian for....................................................... (name of the minor Dependant) through............................................. (name of Guardian) his/her.............................................. (relationship with the Minor)

* Please strike out whichever is not applicable. ** Applicable in the case of a claim by a major dependant. *** Applicable in the case of a claim for a minor dependant.]

[Please refer to rule 58 of the ESI (Central) Rules, 1950].

Forms under



FORM 17 Certificate/Notice of Pregnancy

Maternity Benefit EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 87)

Signature or thumb‐impression of the Insured Woman

Employer’s Code No. ...................................... Book No...................................... Serial No.....................................

Insured Woman’s Name.................................. Insurance No.....................................................

Stamp of the Dispensary

Certified that I have examined the above mentioned Insured Woman today and that in my opinion she is pregnant and her pregnancy appears to be........................ weeks old.

...................................................... Signature of midwife, if any

Date............................. .......................................................

Signature or counter‐signature of Insurance Medical Officer ..................................................... Name in Block Letters and Rubber Stamp

Any other Remarks................................. I, ......................................... Insurance No. ........................................... wife/daughter of .............................. hereby give notice of pregnancy. Present address ...................................................................................................................... Present/last employer........................................................................................................... Date.............................


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FORM 18

Certificate of Expected Confinement/ Confinement/ Miscarriage/Maternity Benefit

EMPLOYEES’ STATE INSURANCE CORPORATION [Regulation 88 and 89]


Employer’s Code No. ...................................... Book No......................................

Serial No..................................... Insured Woman’s Name.................................. Insurance No..................................................... Wife/Daughter of.............................................


I. * Certified that I have examined the above mentioned Insured Woman today and that in my opinion she may expect to be confined on or about ................................

II. * Certified that I attended the above mentioned Insured Woman in connection with her

confinement/miscarriage at.................................................................... (address) and that she was there delivered of a child on the .................... day of .........................

......................................................

Signature of midwife, if any Date......................... ....................................................... Any other Remarks................................. Signature or counter‐signature ................................................................... of Insurance Medical Officer

.

Name in Block Letters and Rubber Stamp.

* Delete whichever is not applicable.

Forms under



FORM 19 Claim for Maternity Benefit

and Notice of Work EMPLOYEES’ STATE INSURANCE CORPORATION

[Regulations 88 (ii), 89 and 91]


Employer’s Code No. ...................................... Book No......................................

Serial No.....................................

Insured Woman’s Name.................................. Insurance No. ................................................... Wife/Daughter of.............................................

Stamp of the Dispensary I, the above mentioned Insured Woman hereby claim Maternity Benefit for expected confinement/confinement*/miscarriage with effect from ............................. I, further declare that I have ceased*/shall cease to work for remuneration with effect from the aforesaid date. *I, do hereby give notice that I have taken up/shall take up work for remuneration with effect from the................ I have drawn maternity benefit only upto .......................... Present/last employer**................................................... Department, shift and occupation................................... Present address.................................................................. Signature or thumb‐impression ............................................................................................. of the Insured Woman Date................. Name of the Branch Office.........

* Please delete whichever not applicable. ** If not in employment, mention the particulars of last employer. IMPORTANT:

1. No work for remuneration should be taken up during the period for which Maternity Benefit is being claimed or is to be claimed.

2. Notice of resumption of work must be sent before any work is taken up. 3. Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for

herself or for some other person commits an offence punishable with imprisonment for a term which may extend up to six months, or with a fine up to Rs. 2000, or with both.

Forms under



FORM 20 Claim for Maternity Benefit after the Death

of an Insured Woman Leaving Behind the Child EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 89A)

Claim arising from the death on......................... of Ms........................................................ wife of/daughter of.........................................., having Insurance No.........................................and last employed by M/s.............................................................................................................. I .........................................., *being related to the above‐named deceased Insured Person as her.................................................. and being her nominee/being her legal representative (applicable if the I.W. dies leaving no nominee), hereby claim Maternity Benefit for the period from ................... to .................. . I also declare that—

1. **the deceased Insured Women died on ....................... leaving behind the child who is still alive; or 2. **the deceased Insured Women died on ....................... leaving behind the child who also died on...............

The amount due may be paid to me by money order/or in cash at Branch Office. I further declare that the particulars, as given here‐in‐above, are true to the best of my knowledge and belief.

Date.................

.................................................... Signature/Thumb‐Impression

of the Claimant Name in Block Letter and................................................. Address of claimant............................................................

............................................................

ATTESTATION ***Certified that the declarations, as made here‐in‐above, are true to the best of my knowledge and belief.

* Strike out this line if not applicable. ** Delete either (i) or (ii), as may not be applicable in the case. *** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a

Municipal Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv) the Head of the Gram‐Panchayat under the official seal of the Panchayat; or M.L.A./M.P.; or (v) A Gazetted Officer of the Central/State Govt./Member of the Local Committee/Regional Board, or (vi) any other authority considered as appropriate by the Branch Manager concerned.

IMPORTANT:

1. This claim form duly filled up, is required to be submitted to the appropriate Branch Office, together with a death certificate in Form 24B, within 30 days of the death of the Insured Woman.

2. Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2000 or with both.


Signature Designation

Forms under



FORM 21 Death Certificate in Case of Confinement

of Claiming Maternity Benefit EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 89A)

Book No................. Name of the deceased insured woman.................................................... Serial No................ w/d of ..................................................

Insurance No.........................................

I certify that in my opinion—

i. the above‐named deceased Insured Woman died on ............................., as a result of ............................................, during her confinement/*during a period of ......................, weeks

(cause of death)

immediately following her confinement, leaving behind the child.

ii. *the said child also died on .............................. as a result of ............................................

Also certified that I had been attending her*/and also her child for providing medical benefit before *her said child’s death and I attended her for the last time on.............................. and her said child for the last time on..............................

Any other remarks ................................................. ................................................. Date......................... ................................................................

Signature of Insurance Medical Officer/ Insurance Medical Practitioner

Note.—

1. *Delete whichever is not applicable. 2. The language may be suitably amended if the Insurance Medical Officer/Insurance Medical Practitioner had

not attended the deceased person before her/his child’s death.


Rubber Stamp and name in Block Letters

Forms under



FORM 22

Funeral Expenses Claim Form EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 95E)

Claim arising from the death on ........................... of .......................................................... s/w/d of.................................................................. aged............... years, having Insurance No........................................................ and last employed as ............................................................by M/s. ................................................................. Code No. ......................................................... I ........................................................................ s/w/d of ................................................. aged .......................... years declare:—

i. *that I am the eldest surviving member of the family of the deceased Insured Person, whose particulars are furnished here‐in‐above, and that I actually incurred an expenditure of Rs. ................................ (Rupees ............................................... only) necessary for the funeral of the said deceased person.

or ii. *that the deceased Insured Person, whose particulars are furnished there‐in‐above, did not have a

family/was not living with his family at the time of his/her death and that I actually incurred an expenditure of Rs. ................................ (Rupees ............................................... only) necessary for the funeral of the said deceased insured person.

Accordingly, I do hereby claim funeral expenses for the amount of Rs. ................................ (Rupees ............................................... only).

Date....................... Name in Block ........................................................ Letters........................ Signature/thumb‐impression of the claimant

ATTESTATION

**Certified that the declarations, as made here‐in‐above, are true to the best of my knowledge and belief.

* Delete either (i) or (ii), which may not be applicable in the case.

** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv) the Head of the Gram‐Panchayat under the official seal of the Panchayat; or M.L.A./M.P.; or (v) a Gazetted Officer of the Central/State Government, Local Committee/Regional Board; or (vi) any other authority considered as appropriate by the Branch Manager concerned.

Important.—Any person who makes a false statement or representation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2000, or with both. Note.—In case of a minor, the guardian should sign the claim form on behalf of the minor and then add the


Signature Designation Date

Forms under



following below his/her signature. ................................................

(Name of the minor) through …………………………..

(Name of the Guardian) his/her ......................................................

(Relationship with the Minor)

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FORM 23 (To be submitted along with claim of June & December)

Life Certificate for Permanent Disablement Benefit EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 107)

Insurance No. of permanently disabled person

*Certified that Sh./Smt. ................................................... w/s/d of ....................................... is alive this day of ................... 20 ......... Name in Block letter of Signature............................................. Signing Claimant. Date................. .............................................................

Designation with Rubber stamp/ seal of the attesting authority

IMPORTANT.—Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six moths or with a fine up to Rs. 2,000, or with both. *This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv) the Head of the Gram‐Panchayat under the official seal of the Panchayat; or (v) an M.L.A./M.P.; or (vi) a Gazetted Officer of the Central/ State Government; or (vii) a member of Local Committee/Regional Board of the ESIC; or (viii) any other authority considered as appropriate by the Branch Manager concerned.

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FORM 24 (To be submitted along with claim of June & December)

Declaration and Certificate for Dependants’ Benefit EMPLOYEES’ STATE INSURANCE CORPORATION

(Regulation 107A)

Name of the deceased Insured person......................... Ins. No.

I ...................................................., being the ......................................... of the above‐named deceased Insured Person and also being his dependant, do hereby solemnly declare:—

i. *that I am not married/re‐married so far.

(to be given only by a female dependant)

ii. *that I have not yet attained the age of eighteen years

(to be given only in respect of a minor male or female dependant).

iii. *that I have attained the age of eighteen years but continue to be infirm.

(to be given by a legitimate/adopted infirm son or by a legitimate/adotped infirm daughter.

Certificate as specified, to be attached, if required)

Present Address:.........................................................................................................................

Date.................... .............................................................

Signature or thumb‐impression of the dependant or

Name in Block letters ............................................................. of signing claimant Signature or thumb‐impression of the Guadian in case of a minor dependant

Name of the Minor........................ Through..........................................

(name of the Guardian) his/her............................................ (relationship with the minor)

CERTIFICATE

**Certified that Sh./Smt./Kumari ................................................... w/s/d of ....................................... is alive this day, the ...................... day of ................... 20 ......... and that the declarations made above are true to the best of my knowledge and belief.


Signature …………………… Designation ……………………..

Date ………………………..

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* Strike out whichever is not applicable.

** This certificate is to be given by (i) an officer of the Revenue, Judicial or Magisterial Department; or (ii) a Municipal Commissioner; or (iii) a Workmen’s Compensation Commissioner; or (iv) the Head of Gram‐Panchayat under the official seal of the Panchayat; or (v) M.L.A./M.P.; or (vi) a Gazetted Officer of the Central/State Government; (vii) a member of the Local Committee/Regional Board of the ESIC; or (viii) any other authority considered as appropriate by the Branch Manager concerned.

IMPORTANT.— Any person who makes a false statement or misrepresentation for the purpose of obtaining benefit, whether for himself or for some other person, commits an offence punishable with imprisonment for a term which may extend up to six months or with a fine up to Rs. 2,000, or with both.

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THE WORKMEN’S COMPENSATION RULES, 1924

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ L 1

Forms under the


Forms under



INDEX FORM AA Deposit of Compensation for Non‐Fatal Accident to

a Woman or Person under Legal Disability

FORM A Deposit of Compensation for Fatal Accident

FORM B Receipt for Compensation

FORM C Statement of Disbursements

FORM D Deposit of Compensation for Non‐Fatal Accidents, other than to a Woman or Person Under Legal Disability

FORM EE Report of Fatal Accidents

FORM E Receipt for Compensation

FORM F Application for Compensation by Workman

FORM G Application for Order to Deposit Compensation

FORM H Application for Commutation

FORM JJ Notice to Appear to Contest the Claim for Compensation

FORM J Notice to Appear to Contest the Claim for Compensation

FORM K Memorandum of Agreement

FORM L Memorandum on Agreement

FORM M Memorandum of Agreement

FORM N Notice to Receive any Objections under an Agreement

FORM O Notice Intimating the Reasons for Which an Agreement Has Been Refused

FORM P Notice Giving Opportunity to Show Cause on Why The Agreement Should be Registered

FORM Q Notice Giving Opportunity to Show Cause on Why The Agreement Should be Registered

FORM R Register of Agreements

Forms under



FORM A [See rule 6 (1)]

Deposit of Compensation for Fatal Accident [Section 8 (1) of the Workmen ʹs Compensation Act, 1923]

1. Compensation amounting to Rs. ..............is hereby presented for deposit in respect of injuries

resulting in the death of the workman, whose particulars are given below, which occurred on ........................ Name ........................ Father’s Name ........................ (Husband’s name in case of married woman and widow.) Caste........................ Local address .................................. Permanent address .................................. His/Her monthly wages are estimated at Rs.................. He/ She was over/ under the age of 15 years at the time of his/her death.

2. The said workman had, prior to the date of his/her death, received the following payments, namely:— Rs. ................ on ........................ Rs. ................ on ........................ Rs. ................ on ....................... Rs. ................ on ........................ Rs. ................ on ........................ Rs. ................ on ....................... amounting in all to Rs.................

3. An advance of Rs .............. has been made on account of compensation to .................. being his/her dependant.

4. *I do not desire to be made a party to the proceedings for distribution of the aforesaid compensation. Dated .................... 20.....

Employer. *An employer desiring to be made a party to the proceedings should strike out the words “do not”.

Forms under



FORM AA [See rule 6 (1)]

Deposit of Compensation for Non‐Fatal Accident to a Woman or Person under Legal Disability

[Section 8 (1) of the Workmen ʹs Compensation Act, 1923] 1. Compensation amounting to Rs ................ is hereby presented for deposit in respect of injuries

sustained by ......................... residing at ................................... on ............... 20..... resulting in the loss of/temporary disablement. His/Her monthly wages are estimated at Rs. ............... He/She was over/under the age of 15 years at the time of the accident.

2. The said injured workman has prior to the date of the deposit received the following half‐ monthly payments, namely:— Rs. .............. on ........................ Rs. .............. on ........................ Rs. .............. on ........................ Rs. .............. on ........................ Rs. .............. on ........................ Rs. .............. on ........................

Dated..............20..... Employer

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FORM B (See rule 6)

Receipt for Compensation [Deposited under section 8 (1) of the Workmen’s Compensation Act, 1923]

Book No. .................................. Receipt No............... Register No. .............. Depositor .............................

Deceased or injured workman ............................. Date of deposit ............ 20..... Sum deposited Rs ...............

Commissioner.

Forms under



FORM C (See rule 6)

Statement of Disbursements [Section 8 (4) of the Workmen’s Compensation Act, 1923]

Serial No. ............. Depositor ....................................... Date .....................20.......... Amount deposited....................... Amount deducted and repaid to the employer under the proviso to section 8 (1) ........ Funeral expenses paid ............ Compensation paid to the following dependants :

Name Relationship

Total —

Dated .................. 20..... Commissioner

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FORM D [See rule 9]

Deposit of Compensation for Non‐Fatal Accidents, other than to a Woman or Person under Legal Disability

[Section 8 (2) of the Workmen’s Compensation Act, 1923] Compensation amounting to Rs. .............. is hereby presented for deposit in respect of

permanent/temporary injuries sustained by .................. residing at ....................... which occcurred on........... 20.....

Dated .............. 20.....

Employer

Forms under



FORM E (See rule 9)

Receipt for Compensation [Deposited under section 8 (2) of the Workmen’s Compensation Act, 1923]

Book No. .............. Receipt No. .............. Register No. .............. Depositor ............................ In favour of ............................ Date of deposit .............. 20..... Sum deposited Rs. ..............

Commissioner

Forms under



FORM EE [See rule 11]

Report of Fatal Accidents To

...................

................... Sir,

I have the honour to submit the following report of an accident which occurred on................... (date) at ................... (here enter details of premises) and which resulted in the death of the workman/workmen of whom particulars are given in the statement annexed.

2. The circumstances attending the death of the workman/workmen were as under : (a) Time of the accident (b) Place where the accident occurred (c) Manner in which deceased was/were employed at the time (d) Cause of the accident (e) Any other relevant particulars

I have etc. (Signature and designation of person making the report.)

STATEMENT

Name Sex Age Nature of Employment

Full Postal Address

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C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ L 1 0

FORM F (See rule 20)

Application for Compensation by Workman To

The Commissioner for Workmen’s Compensation, ............................................................................. .................... residing at..........................applicant, Versus ..................residing at................................opposite party. It is hereby submitted that—

1. The applicant, a workman employed by (a contractor with) the opposite party on the .............. day of .............. 20....., received personal injury by accident arising out of and in the course of his employment. The cause of the injury was (here insert briefly in ordinary language the cause of the injury)..................................................................................................................................................

2. The applicant sustained the following injuries, namely:— ............................................................................................................................................................. 3. The monthly wages of the applicant amounts to Rs .............. The applicant is over/under the age of 15 years.

4. *

a) Notice of the accident was served on the .............. day of ........................ b) Notice was served as soon as practicable. c) Notice of the accident was not served (in due time) by reason of .......................

5. The applicant is accordingly entitled to receive — a) half‐monthly payment of Rs.......from the............ day of 20..... to .................. b) a lump sum payment of Rs ..........

6. The applicant has taken the following steps to secure a settlement by agreement, namely .................................but it has proved impossible to settle the questions in dispute because................................................................................................................................... * You are therefore requested to determine the following questions in dispute, namely:— a) whether the applicant is a workman within the meaning of the Act ; b) whether the accident arose out of or in the course of the applicant’s employment; c) whether the amount of compensation claimed is due, or any part of that amount; d) whether the opposition party is liable to pay such compensation as is due ; e) etc. (as required) .

Dated ........................ 20.... Applicant.

*Strike out the clauses which are not applicable.

Forms under



FORM G (See rule 20)

Application for Order to Deposit Compensation To

The Commissioner for Workmen’s Compensation, ......................................................... .............................................................................................................................................................. ........................ residing at ................................. applicant,

versus ...................... residing at................................. opposite party.

It is hereby submitted that— 1. ........................ a workman employed by (a contractor with) the opposite party on the ..............day

of..............20....., received personal injury by accident arising out of land in the course of his employment resulting in his death on the ..............day of.............. 20....., The cause of the injury was (here insert briefly in ordinary language the cause of the injury) ................................................................................................................ ...........................................................................................................................................

2. The applicant(s) is/are dependant(s) of the deceased workman being his ...................... 3. The monthly wages of the deceased amounts to Rs .............. The deceased was over/under the age of

15 years at the time of his death. 4. *

a) Notice of the accident was served on the .............. day of ...................... b) Notice was served as soon as practicable. c) Notice of the accident was not served (in due time) by reason of.................................

5. The deceased before his death received as compensation the total sum of Rs. .............. The applicant(s) is/are accordingly entitled to receive a lump sum payment of Rs ..............

You are therefore requested to award to the applicant the said compensation or any other compensation to which he may be entitled. Dated ................... 20.....

……………………………… Applicant.

*Strike out the clauses which are not applicable

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FORM H (See rule 20)

Application for Commutation [Under section 7 of the Workmen’s Compensation Act, 1923]

To The Commissioner for Workmen’s Compensation, .................................................................................... .................................................................................... ....................... residing at ................................applicant, Versus ..................... residing at .............................. opposite party. It is hereby submitted that — 1. The applicant/opposite party has been in respect of half‐monthly payments from ...................... to

..................... in respect of temporary disablement by accident arising out of and in the course of his employment.

2. The applicant is desirous that the right to receive half‐monthly payments should be redeemed. 3.

a) The opposite party is unwilling to agree to the redemption of the right to receive half‐monthly payments.

b) The parties have been unable to agree regarding the sum for which the right to receive half‐monthly payments should be redeemed.

You are therefore requested to pass orders — a) directing that the right to receive half‐monthly payments should be redeemed, b) fixing a sum for the redemption of the right to receive half‐monthly payments.

Dated .................... 20.....

……………………………… Applicant

*Strike out the clauses which are not applicable.

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FORM J (See rule 39) NOTICE

Whereas a claim for compensation has been made by...................... applicant, against........................ and the said........................ has claimed that you are liable under section 12(2) of the Workmen’s Compensation Act, 1923, to indemnify him against any compensation which he may be liable to pay in respect of the aforesaid claim, you are hereby informed that you may appear before me on ...................... and contest the claim for compensation made by the said applicant or the claim for indemnity made by the opposite party. In default of your appearance you will be deemed to admit the validity of any award made against the opposite party and your liability to indemnify the opposite party for any compensation recovered from him.

Dated ................... 20.....

Commissioner.

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FORM JJ (See rule 39) NOTICE

Whereas a claim for compensation has been made by ........................ applicant, against ........................and the said........................ has claimed that........................is liable under section 12(2) of the Workmen’s Compensation Act, 1923, to indemnify him against any compensation which he may be liable to pay in respect of the aforesaid claim, and whereas the said........................ on notice served has claimed that you ........................stand to him in the relation of a contractor whom the applicant ........................could have recovered compensation you are hereby informed that you may appear before me on........................and contest the claim for compensation made by the said applicant or the claim for indemnity made by the opposite party ........................ In default of your appearance you will be deemed to admit the validity of any award made against the opposite party........................and your liability to indemnify the opposite party ........................ for any compensation recovered from him.

Dated ................... 20..... Commissioner.

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FORM K (See rule 48)

Memorandum of Agreement It is hereby submitted that on the ........... day of .............. 20..... personal injury was caused

to........................residing at................................ by accident arising out of and in the course of employment in ........................ The said injury has resulted in temporary disablement to the said workman whereby it is estimated that he will be prevented from earning more than of his previous/any wage for a period of........... months. The said workman has been in receipt of half‐monthly payments which have continued from the ........... day of...........20 ..... until the ........... day of...........20..... amounting to Rs . ........... in all. The said workmen’s monthly wages are estimated at Rs........... The workman is over the age of 15 years/will reach the age of 15 years on ....................

It is further submitted that .................... the employer of said workman has agreed to pay, and the said workman has agreed to accept, the sum of Rs ........... in full settlement of all and every claim under the Workmen’s Compensation Act, 1923, in respect of all disablement of a temporary nature arising out of the said accident, whether now or hereafter to become manifest. It is, therefore, requested that this memorandum be duly recorded.

Dated.................20....... Signature of employer....................................... Witness........................ Signature of workman........................ Witness........................ Note.—An application to register an agreement can be presented under the signature of one party,

provided that the other party has agreed to the terms. But both signatures should be appended, whenever possible.

Receipt to be filled in when the money has actually been paid In accordance with the above agreement, I have this day received the sum of

Rs. ...............

........................Workman. Dated ................... 20.....

The money has been paid and this receipt signed in my presence. ........................Witness. Note.—This form may be varied to suit special cases, e.g., injury by occupational diseases, agreement

when workman is under legal disability, etc.

Revenue Stamp

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FORM L (See rule 48)

Memorandum of Agreement It is hereby submitted that on the day of .................... 20..... personal injury was caused to

........................ residing at ................................by accident arising out of and in the course of his employment in ........... . The said injury has resulted in permanent disablement to the said workman of the following nature, namely:—

.................................................................................................................................................... The said workman’s monthly wages are estimated at Rs. ............... The workman is over the age of 15 years/will reach the age of 15 years on ........................ The said

workman has, prior to the date of this agreement received the following payments namely:— Rs. ............... on. ........................ Rs. ............. on ........................ Rs. ............... on. ........................ Rs. ............. on ........................ Rs. ............... on. ........................ Rs. ............. on ........................ It is further submitted that ........... the employer of the said workman, had agreed to pay, and the said

workman has agreed to accept the sum of Rs .................in full settlement of all and every claim under the Workmen’s Compensation Act, 1923, in respect of the disablement stated above and all disablement now manifest. It is, therefore, requested that this memorandum be duly recorded.

Dated ................... 20..... Signature of employer ........................ Witness ........................ Signature of workman ........................ Witness ........................ Note.—An application to register an agreement can be presented under the signature of one party,


Receipt to be filled in when the money has actually been paid In accordance with the above agreement, I have this day received the sum of Rs .....

....................Workman. Dated ................... 20.....

The money has been paid and this receipt signed in my presence. .......................Witness. Note.—This form may be varied to suit special cases, e.g., injury by occupational disease, agreement

when workman is under legal disability. etc.

Revenue Stamp

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FORM M (See rule 48)

Memorandum of Agreement It is hereby submitted that on the ............... day of ................20..... personal injury was caused to

........................ residing at ................................ by accident arising out of and in the course of employment in

....................... The said injury has resulted in temporary disablement to the said workman, who is at present in receipt of wages amounting to Rs. ........................ per month/ no wages . The said workman’s monthly wages prior to the accident are estimated at Rs ............ The workman is subject to a legal disability by reason of........................................................................................................................................... .....................................................................................................................

It is further submitted that ........................., the employer of the workman has agreed to pay and ........................ on behalf of the said workman has agreed to accept half‐monthly payments at the rate of Rs. .............. for the period of the said temporary disablement. This agreement is subject to the condition that the amount of the half‐monthly payments may be varied in accordance with the provisions of the said Act, on account of an alteration in the earnings of the said workman during disablement. It is further stipulated that all rights of commutation under section 7 of the said Act are unaffected by this agreements. It is, therefore, requested that this memorandum be duly recorded.

Dated .................. 20...... Signature of employer. Witness ........................ Signature of workman ........................ Witness ........................ Note.—An application to register an agreement can be presented under the signature of one party,


Receipt to be filled in when the money has actually been paid In accordance with the above agreement, I have this day received the sum of Rs.......

.....................Workman.

Dated ................... 20.... The money has been paid and this receipt signed in my presence. ...................................Witness. Note.—This form may be varied to suit special cases, e.g., injury by occupational disease, etc.

Revenue Stamp

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FORM N (See rule 49)

Whereas an agreement to pay compensation is said to have been reached between ........................ and ........................and whereas ........................has/have applied for registration of the agreement under section 28 of the Workmen’s Compensation Act, 1923, notice is hereby given that the said agreement will be taken into consideration on .................... 20...., and that any objections to the registration of the said agreement should be made on that date. In the absence of valid objections it is my intention to proceed to the registration of the agreement.

Dated ................... 20..... Commissioner

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FORM O (See rules 49 and 50)

Take notice that registration of the agreement to pay compensation is said to have been reached between you ........................ and........................on the .................20.... has been refused for the following reasons, namely :— ............................................................................................................................................................... ............................................................................................................................................................... Dated.................... 20....

Commissioner

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FORM P (See rule 50)

Whereas an agreement to pay compensation is said to have been reached between ........................ and ........................ and whereas ........................has /have applied for registration of the agreement under section 28 of the Workmen’s Compensation Act, 1923, and whereas it appears to me that the said agreement ought not to be registered for the following reasons, namely:— ..................................................................................................................................................................... an opportunity will be afforded to your showing of cause on ..................19...../20....., why the said agreement should be registered. If no adequate cause is shown on that date registration of the agreement will be refused. Dated..................

Commissioner

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FORM Q (See rule 50)

Whereas an agreement to pay compensation is said to have been reached between ........................ and........................and whereas ........................ has/have applied for registration of the agreement under section 28 of the Workman’s Compensation Act, 1923, and whereas it appears to me that the said agreement ought not to be registered for the following reasons, namely:— ........................................................................................................................................................... ........................................................................................................................................................................... an opportunity will be afforded to the said ........................of showing cause on ....................20..... why the said agreement should be registered. Any representation which you have to make with regard to the said agreement should be made on that date. If adequate cause is then shown, the agreement may be registered. Dated ...................20.....

Commissioner

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FORM R (See rule 52)

REGISTER OF AGREEMENTS FOR THE YEAR 20....... ......

Serial

Number Date of

Agreement Date of

RegistrationEmployer Workman

Initials of Commissioner

Reference to orders rectifying the register

Forms under THE MINIMUM WAGES (CENTRAL) RULES, 1950

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ M 1

Forms under the THE MINIMUM WAGES (CENTRAL) RULES, 1950



INDEX FORM I

Register of Fines

FORM II Register of Deductions for Damage or Loss Caused to the Employer, by the Neglect or Default of the Employed Persons

FORM III Annual Returns

FORM IV Overtime Register for Workers

FORM V Muster Roll

FORM VI Form of Application by an Employee Under Section 20(2)

FORM VIA Form of Group Application Under Section 21(1)

FORM VII Form of Application by an Inspector or Person Acting With the Permission of the Authority Under Section 20(2)

FORM VIII

Form in Authority in Favour of a Legal Practitioner or any Official of a Registered Trade Union Referred to in Section 20(2)

FORM IX

Form of Summons to the Opponent to Appear Before the Authority When an Application Under Sub‐Section (2) of Section 20 or Under Section 21 is Entertained

FORM X Register of Wages

FORM XI Wage Slip



FORM I Register of Fines

[Rule 21(4)]

..............................................Employer……………………………………..

Serial No.

Name Fatherʹs/ Husbandʹs Name

Sex Department Nature and date of the offence for

which fine

imposed

Whether workman showed cause

against fine or not, if so enter date

Rate of wages

Date and amount of fine imposed

Date on which fine

realized

Remarks

1 2 3 4 5 6 7 8 9 10 11



FORM II Register of Deductions for Damage or Loss Caused to the Employer,

by the Neglect or Default of the Employed Persons

[Rule 21(4)] ..............................................Employer………………………….

Serial No.


Sex Department Damage or loss caused

with date

Whether worker

showed cause against

deduction, if so, enter date

Date and amount

of deduction imposed

Number of, installments,

if any

Date on which total

amount realized

Remarks

1 2 3 4 5 6 7 8 9 10 11



FORM III [Rule 21(4A)]

Annual Returns Returns for the year ending the 31st December................................................................

1. a. Name of the establishment and postal address.....................................................

b. Name and residential address of the owner/contractor......................................

c. Name and residential address of the Managing Agent/Director/Partner in charge of the day‐to‐day affairs of the establishment owned by a company, body corporate or Association................................................................

2. Number of days worked during the year................................................................. 3. *Number of mandays worked during the year..........................................................

4. †Average daily number of persons employed during the year..............................

(i) Adults (ii) Children

5. Total wages paid in cash……………………………………………………….. 6. ††Total cash value of the wages paid in kind…………………………………………….. 7. Deductions:

Number of cases Total Amount Rs P

a. Fines b. Deductions for damage or loss c. Deductions for breach of contract

Disbursement from fines:

Purpose Amount Rs. nP.

(a) (b) (c) (d)

8. Balance of fine fund in hand at the end of the year..................................................

Dated................. Signature.............................

Designation........................

* This is the aggregate number of attendance during the year. † The average daily number of persons employed during the year as obtained by dividing the aggregate number of

attendances during the year by the number of working days. †† Cash value of the wages paid in kind should be obtained by taking the difference between the cost price paid by

the employer and the actual price paid by the employees for supplies of essential commodities given at concessional rates.



FORM IV Overtime Register for Workers

[Rule 25(2)]

Month ending...........20.......

Sl. No.


Sex Designation and Department

Dates on which

overtime worked

Extent of overtime on

each occasion


production in case of piece‐workers

1 2 3 4 5 6 7 8

Normal hours Normal rate Overtime rate

Normal earnings

Overtime earnings

Total earnings

Date on which

overtime payment made

9 10 11 12 13 14 15



FORM V Muster Roll

[Rule 26(5)]

Name of Establishment................................................... Place.......................................................

S.No. Name Fatherʹs/

Husbandʹs Name

Sex Nature of

work

For the period ending…….. [Total attendance] Remarks.....................

1 2 3 4 5



FORM VI Form of Application by an Employee under Section 20(2)

In the Court of the Authority appointed under the Minimum Wages Act, 1948, for.. . . . . . . . . . . . . . . . . . . . . . . . . . .area.

Application No........................... of 20......... (1).......................................................................Applicant (through........................ a legal practitioner/an official of

................... which is a registered Trade Union), Address................................................

Versus (1)................................................ (2)................................................ (3)................................................ Opponent(s) Address................................................ The applicant above named states as follows:—

1) The applicant was/has been employed from.............to..........as..........(Category) in........................(establishment) of Shri/Messrs...............engaged in............... (nature of work) which is a scheduled employment within the meaning of section 2(g) of the Minimum Wages Act.

2) The opponent(s) is/are the employer(s) within the meaning of section 2(e) of the Minimum Wages Act.

3)

a. * The applicant has been paid wages at less than the minimum rate of wages fixed for his category of employment under the Act by Rs.........per day for the period from.........to...........;

b. * The applicant has not been paid wages at Rs.....................per day for weekly days of rest from........to..........;

c. * The applicant has not been paid wages at the over time rate for the period from................to............

4) The applicant estimates the value of relief sought by him on each account as under:

a. Rs..............................

b. Rs..............................

c. Rs.............................. Total Rs..............................

5) The applicant, therefore, prays that a direction may be issued under section 20(3) of the Act for:

a. * payment of the difference between the wages payable under the Minimum Wages Act and the wages actually paid.

b. * payment of remuneration for the days of rest. c. * payment of wages at the overtime rates. d. compensation amounting to Rs........



6) The applicant begs leave to amend or add to or make alterations in the application, if and when necessary, with the permission of the Authority.

7) The applicant does solemnly declare that the facts stated in this application are true to the best of his knowledge, belief and information.

Date..........................

Signature or thumb impression of the employed person, or legal practitioner or official of a Registered Trade Union duly authorized.

*Delete the portions not required.


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ M 1 0

FORM VIA Form of Group Application under Section 21(1)

In the Court of the Authority appointed under the Minimum Wages Act, 1948 for.......................... area Application No.........................of 20................ Between A.B.C. and (state the number)............................others: Applicants (through a legal practitioner/an official of ......................... which is a registered trade Union), Address..........................

and x.y.z ...........................................................opposite party Address..........................

The applicants state as follows:— 1) The applicants whose names appear in the attached schedule were/have been employed from..............

to................ as............... (Categories).................... in................ (Establishment) of Shri/Messrs............. engaged in .................... (nature of work) which is/are scheduled employment(s) within the meaning of section 2(g) of the Minimum Wages Act.

2) The opponent(s) is/are the employer(s) within the meaning of section 2(e) of the Minimum Wages Act. 3)

a. *the applicants have been paid wages at less than the minimum rates of wages fixed for their category (categories) of employment(s) under the Act by Rs................ per day for the period (s) from...............to.......;

b. *The applicants have not been paid wages at Rs............. per day for the weekly days of rest from..............to..................;

c. *The applicants have not been paid wages at the overtime rates(s) for the period from............ to........................;

4) The applicants estimate the value of relief sought by them on each account as under:

a. Rs........................

b. Rs........................

c. Rs........................ Total Rs.....................

5) The applicants, therefore, pray that a direction may be issued under section 20(3) of the Act for:

a. *payment of the difference between the wages payable under the Minimum Wages Act and the wages actually paid;

b. *payment of remuneration for the days of rest;

c. *payment of wages at the overtime rate(s);

d. compensation amounting to Rs........



6) The applicants beg leave to amend or add to or make alterations in the application, if and when necessary, with the permission of the Authority.

7) The applicants do solemnly declare that the facts stated in this application are true to the best of their knowledge, belief and information.

Date........................

Signature or thumb impression of the employed persons or legal practitioner, or official of a Registered Trade Union duly authorized.

*Delete the portions not required.



FORM VII Form of Application by an Inspector or Person Acting with

the Permission of the Authority under Section 20(2)

In the Court of the Authority appointed under the Minimum Wages Act, 1948, for.................................area.

Application No.............................. of 20................ (1) ........................................................................Applicant Address................................................................................

Versus

(1) ....................................................................Opponent(s) Address................................................................................ The applicant above named states as follows:— 1. The opponent(s) has/have—

a. *paid wages at less than the minimum rates of wages fixed for their cateogry (categories) of employment(s) under the Act by Rs...................... per day for the period(s) from........................to........................;

b. *not paid wages at Rs.............................per day for the weekly days of rest from...........................to.....................; c. *not paid wages at overtime rate(s) for the period from.................. to...........to the following employees;

2. The applicant estimates the value of relief sought for the employees on each account as under:

a. Rs........................

b. Rs........................

c. Rs........................ Total Rs........................

3. The applicant, therefore, prays that a direction may be issued under section 20(3) of the Act for:

a. *payment of the difference between the wages payable under the Minimum Wages Act and the wages actually paid;

b. *payment of remuneration for the days of rest; c. *payment of wages at the overtime rate(s); d. compensation amounting to Rs............

4. The applicant begs leave to amend or add to or make alternations in the application, if and when necessary, with the permission of the Authority.

5. The applicant does solemnly declare that the facts stated in this application are true to the best of his knowledge, belief and information. Date....................... Signature……………………… *Delete the portion not required.



FORM VIII Form in Authority in Favour of a Legal Practitioner or any Official

of a Registered Trade Union Referred to in Section 20(2) In the Court of the Authority appointed under the Minimum Wages Act, 1948

for.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .area. Application No.....................of 20.......... (1).......................................................................................................................... (2).......................................................................................................Applicant(s)† (3) .......................................................................................................................

Versus (1) ................................................................................................................................... (2) .......................................................................................................Opponent(s) (3) ...................................................................................................................... I hereby authorize Mr. ..........................a legal practitioner/an official of the registered trade union of

.......................... to appear and act on my behalf in the above described proceedings and to do all things incidental to such appearing and acting.

Date.......................

Signature or thumb impression of the employee.

† When the application is by a group of employees, the thumb impression or signatures of two of the applicants need be put to the application and a full list of applicants should be attached to the application.



FORM IX Form of Summons to the Opponent to Appear Before the Authority

When an Application under Sub‐Section (2) of Section 20 or under Section 21 is Entertained

(Title of the application) To...................................................(Name, description and place of residence) Whereas........................has made the above said application to me under the Minimum Wages Act, 1948, you are

hereby summoned to appear before me in person or by a duly authorised agent, and able to answer all material questions relating to the application, or who shall be accompanied by some person able to answer all such questions on the.........day of ........20............. at................ Oʹclock in the................. noon, to answer the claim; and as the day fixed for the appearance is appointed for the final disposal of the application, you must be prepared to produce on that day all the witnesses upon whose evidence and all the documents upon which you intend to rely in support of your defence.

Take notice that in default of your appearance on the day before mentioned, the application will be heard and determined in your absence.

Date..................... Signature.



FORM X [Rule 26(1)]

Register of Wages

Name of Establishment.......................

Wages period from....................to..................Place..................

Sl. No.

Name of the employee


Designation Minimum rates of wages payable

Rates of wages actually paid

Basic D.A. Basic D.A.

1 2 3 4 5 6 7 8

Total attendance/ units of work done

Overtime worked

Gross wages payable

Employeeʹs contribution to P.F.

Deductions

Wages paid

Date of payment

Signature or Thumb‐Impression of employee H.R.

Other deduction

Total deduction

9 10 11 12 13 14 15 16 17 18



FORM XI [Rule 26(2)]

Wage Slip Name of the establishment....................................

Place.............................................. 1. Name of employee with fatherʹs/husbandʹs name.......................................... 2. Designation 3. Wages Period. 4. Rate of wages payable:

(a) Basic (b) D.A.

5. Total attendance/units of work done 6. Overtime wages. 7. Gross wages payable 8. Total deductions 9. Net wages paid

Pay‐in‐charge Employeeʹs signature/thumb impression].

Forms under PAYMENT OF WAGES (PROCEDURE) RULES, 1937

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ N 1

Forms under

PAYMENT OF WAGES (PROCEDURE) RULES, 1937



INDEX

FORM A

Form of Individual Application

FORM B

Form of Group Application

FORM C

Form of Application by an Inspector or Person Permitted by the Authority or Authorised to Act

FORM D

Certificate of Authorisation

FORM E

Notice for the Disposal of Application

FORM F

Record of Order or Direction

FORM G

Notice to Respondent of the Day Fixed for The Hearing of the Appeal under Section 17 of The Payment of Wages Act, 1936



FORM A Form of Individual Application

[See Sub‐Section (2) of Section 15 of the Payment of Wages Act]

In the Court of the Authority appointed under the Payment of Wages Act, 1936 (IV of 1936) for ................................... area.

Application No..................... of 20..... Between A.B.C.................................................................................Applicant through………………………………………………………

a legal practitioner ……………………………………………………………………

an official of (which is a registered Trade Union.) And X.Y.Z........................................................................................opposite party:

The applicant states as follows:—

1. A.B.C. is a person employed in/on the factory/railway/industrial establishment entitled and resides at......................................................................................

The address of the applicant for the service of all notices and processes is:

...................................................................................................................................

2. X.Y.Z., the opposite party, is the person responsible for the payment of his wages under section 3 of the Act, and his address for the service of all notices and processes is ................................................................................................................................

3.

(1) The applicant’s wages have not been paid for the following wage‐period(s) ................[give (dates)]

Or

A sum of Rs..........................has been unlawfully deducted from his wages of ............... amount for the wage‐period(s) which ended on...............[(give date(s)].

(2) [Here give any further claim or explanation].

4. The applicant estimates the value of the relief sought by him at the sum of Rs..........................

5. The applicant prays that a direction may be issued under sub‐section (3) of section 15 for—

a. Payment of delayed wages as estimated or such greater or lesser amount as the Authority may find to be due;

Or Refund of the amount illegally deducted;

b. Compensation amounting to ...................................

The applicant certifies that the statement of facts contained in this application is to the best of his knowledge and belief accurate.

...................................................................

Signature or thumb impression of the employed

person, or legal practitioner, or official of a

registered trade union duly authorized.



FORM B Form of Group Application

[See Sub‐Section (2) of Sections 15 and 16 of Payment of Wages Act]

In the Court of the Authority appointed under the Payment of Wages Act, 1936 (IV of 1936) for ....................................area.

Application No............... of 20.....

Between A.B.C and (state the number)................................................................ others, Applicants a legal practitioner through an official of....................................................................... (which is a registered trade union).

And X.Y.Z....................................................................................................opposite party.

The applicants state as follows:—

1. The applicant whose names and permanent addresses appear in the attached schedule are persons employed in /on the/factory/railway/industrial establishment entitled..

The address of the applicants for service of all notices and processes is:

2. X.Y.Z, the opposite party, is the person responsible for the payment of wages under section 3 of the Act, and his address for the service of all notices and processes is:.

3. The applicants’ wages have not been paid for the following wage‐period(s):

4. The applicants estimate the value of the relief sought by them at the sum of Rs................

5. The applicants pray that a direction may be issued under sub‐section (3) of section 15 for:—

a. Payment of the applicants’ delayed wages as estimated.........................or such greater or lesser amount as the Authority may find to be due.

b. Compensation amounting to.........................

The applicants certify that the statement of facts contained in this application is to the best of their knowledge and belief accurate.

...........................................................................

Signature or thumb impression of two of the applicants, or legal practitioner, or an official of a registered trade union

duly authorised.

SCHEDULE

S.NO.

NAME OF APPLICANT PERMANENT ADDRESS

1 2 3



FORM C Form of Application by an Inspector or Person Permitted by the Authority

or Authorized to Act [See Sub‐Section (2) of Sections 15 and 16 of the Payment of Wages Act]

In the Court of Authority appointed under the Payment of Wages Act, for.........................area.

Application No..............of 20.....

Between

A.B.C.[(designation)....................................................................an Inspector under the

Payment of Wages Act] or a person/permitted by the authority/authorised ................................................................................to act under sub‐section (2) of section 15........................................................................................... applicant.

And

X.Y.Z.................................................................................................the opposite party.

The applicant states as follows:—

1. X.Y.Z., the opposite party is the person responsible under the Act for the payment of wages to the following persons whose names and permanent addresses are given below:

1)

2)

3)

2. His address for the service of all notices and processes is:

3. The wages of the said person(s) due in respect of the following wage‐period(s) have not been paid/have been subjected to the following illegal deductions:

4. The applicant estimates the value of the relief sought for the person(s) employed at the sum of Rs..........................

5. The applicant prays that a direction may be issued under Sub‐Section (3) of Section 15 for:—

a. Payment of the delayed wages as estimated or such greater or lesser amount as the Authority may find to be due.

Or Refund of the amount illegally deducted.

b. Compensation amounting to Rs..........................

The applicant certifies that the statement of facts contained in this application is to the best of his knowledge and belief accurate.

...............................

Signature



FORM D Certificate of Authorization

I/We employed person(s) hereby authorise a legal practitioner/an official of................................ which is a registered trade union to act on my/our behalf under section 15 and section 17 of the Payment of Wages Act, 1936 (IV of 1936), in respect of the claim against.........................on account of the delay in payment/illegal deduction from my/our wages for.........................

Witnesses Signatures

(1) (1)

(2) (2)

(3) (3)

(4) (4)

I accept the authorisation.

.............................................

Signature

Legal practitioner/ Official of a registered trade union



FORM E Notice for the Disposal of Application

To

Whereas under the Payment of Wages Act, 1936 (IV of 1936) a claim against you has been presented to me in the application of which a copy is enclosed, you are hereby called upon to appear before me either in person or by any person duly instructed, and able to answer all material questions relating to the application, or who shall be accompanied by some person able to answer all material questions relating to the application, or who shall be accompanied by some person able to answer all such questions, on the ........................day of.........................20.........at............o’clock in the forenoon/afternoon to answer the claim; and as the day fixed for your appearance is appointed for the final disposal of the application, you must be prepared to produce on that day all the witnesses upon whose evidence, and the documents upon which you intend to rely in support of your defence.

Take notice that, in default of your appearance on the day before mentioned, the application will be heard and determined in your absence.

Given under my hand and seal, this day of..............20......

.........................

Authority

SEAL



FORM F Record of Order or Direction

1) Serial number.........................

2) Date of the application.........................

3) Name or names, parentage, address or addresses of the applicants, or some, or all of the applicants belonging to the same unpaid group……………………………………………..

4) Name and address of the employer……………………………….

5) Amount claimed…………………..

a. as delayed wages: Rs ..........................

b. as deducted from wages: Rs.........................

6) Plea of the employer and his examination (if any):

7) Finding, and a brief statement of the reasons therefor…………………….

8) Amounts awarded……………

a. Delayed wages ........................

b. Deducted wages.........................

9) Compensation awarded.........................

10) Penalty imposed.........................

11) Costs awarded to:

a. Court‐fee charges.........................

b. Pleader’s fee.........................

c. Witnesses’ expenses.........................

12) Date by which the amounts awarded shall be paid.

Signed.........................

Dated..........................

Note:—In case where an appeal lies, attach on a separate sheet the substance of the evidence.



FORM G Notice to Respondent of the Day Fixed for the Hearing of the Appeal under

Section 17 of the Payment of Wages Act, 1936

Appeal from the decision of the Authority for the................................... area dated the..............day of..................20......

To

Respondent

Take notice that an appeal of which a copy is enclosed, from the decision of the Authority for...................................area has been presented by X.Y.Z. (and others), and registered in this Court, and that the ..............day of..............20....., has been fixed by this Court for the hearing of the appeal.

If no appearance is made on your behalf by yourself, or by some one by law authorised to act for you in this appeal, it will be heard and decided in your absence.

Given under my hand and the seal of the Court, this...............day of...............20......

.........................

Judge

Forms under PAYMENT OF GRATUITY (CENTRAL) RULES, 1972

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ O 1

Forms under

PAYMENT OF GRATUITY (CENTRAL) RULES, 1972



INDEX FORM A Notice of Opening

FORM B Notice of Change

FORM C Notice of Closure

FORM D Notice for Excluding Husband from Family

FORM E Notice of Withdrawal of Notice for Excluding Husband from Family

FORM F Nomination

FORM G Fresh Nomination

FORM H Modification of Nomination

FORM I Application of Gratuity by an Employee

FORM J Application for Gratuity by a Nominee

FORM K Application for Gratuity by a Legal Heir

FORM L Notice for Payment of Gratuity

FORM M Notice Rejecting Claim for Payment of Gratuity

FORM N Application for Direction

FORM O Notice for Appearance Before the Controlling Authority

FORM P Summons

FORM Q Particulars of Application under Section 7

FORM R Notice for Payment of Gratuity

FORM S

Notice for Payment of Gratuity as Determined by Appellate Authority

FORM T Application for Recovery of Gratuity



FORM ‐A [See Sub‐Rule (1) of Rule 3]

Notice of Opening

1. Name and address of the Establishment. 2. Name and designation of the Employer 3. Number of persons employed. 4. Maximum number of persons employed on any day during the preceding twelve months with date. 5. Number of employees covered by the Act. 6. Nature of industry. 7. Whether seasonal. 8. Date of opening. 9. Details of Head Office/Branches.

a) Name and address of the head office. Number of employees. b) Names and addresses of other branches in India.

1. 2. 3.

I verify that the information furnished above is true to the best of my knowledge and belief. Place............................. Signature of the employer Date............................. with name and designation To The Controlling Authority ........................................ .......................................



FORM ‐B [See Sub‐Rule (2) of Rule 3]

Notice of Change Name and address of the Establishment,

Take notice that following changes have taken place with effect from ....................... in the particulars furnished by me in notice dated ........................... on Form ‘A’.

Name. Address. Name of the employer. Nature of business Place............................. Signature of the employer Date............................. with name and designation To The Controlling Authority ........................................ ........................................



FORM ‐C [See Sub‐Rule (3) of Rule 3]

Notice of Closure Take notice that it is intended to close down the establishment with effect from .................. The other details are

furnished below:

1. Name and address of the establishment. 2. Name and address of the Head Office, if any. 3. Name and designation of the employer. 4. Number of persons in employment. 5. Number of employees entitled to Gratuity. 6. Amount of Gratuity involved.

Place............................. Signature of the employer Date............................. with name and designation To The Controlling Authority ........................................ ......................................



FORM‐D [See Sub‐Rule (1) of Rule 5]

Notice for Excluding Husband from Family From ............................................................................. 1. Name of the female employee. 2. Name or description of establishment where employed. 3. Post held with Ticket or Serial No., if any. 4. Department/Branch/Section where employed. 5. Permanent address.

Take notice that I, Shrimati ..................... desire to exclude my husband Shri .....................from my family for the purposes of the Payment of Gratuity Act, 1972. Place............................. Signature/Thumb impression Date............................. of the employee.

Declaration by witnesses

The above notice was signed/thumb impressed before me. Name in full and full Signature of witnesses. address of witnesses. 1. 1. 2. 2. Place............................ Date............................. To The Controlling Authority. (Through the employer) [Name and address of the employer here]

For use by the employer Received and recorded in this establishment.

Date............................. Reference No. Signature of the employer or an officer authorised in this behalf by the employer

To 1. ............................... (Employee) 2. The Controlling Authority. Note : strike out the words not applicable



FORM ‐ E [See Sub‐Rule (2) of Rule 5]

Notice of Withdrawal of Notice for Excluding Husband from Family 1. Name of the female employee. 2. Name or description of establishment where employed. 3. Post held with Ticket or Serial No., if any. 4. Department/Branch/Section where employed. 5. Permanent address.

Take notice that I, Shrimati .................... hereby withdraw the notice dated .................... whereby I exclude my husband Shri ................... from my family for the purposes of the Payment of Gratuity Act, 1972. The earlier notice was recorded under your reference No. ............dated ......................... Place............................. Signature/Thumb impression Date............................. of the employee.

Declaration by witnesses The above notice of withdrawal was signed/thumb impressed before me. Name in full and full Signature of witnesses. address of witnesses. 1. 1. 2. 2. Place............................ Date............................. To The Controlling Authority.(Through the employer) [Name and address of the employer]

For use by the employer Received and recorded in this establishment.

Reference No. Date.............................

To 1. ........................... (Employee) 2. The Controlling Authority.

Note : strike out the words not applicable

Signature of the employer or officer authorized or Seal or rubber stamp of the establishment.



FORM ‐ F [See Sub‐Rule (1) of Rule 6]

Nomination To ...............................................................................................................................................

[Give here name or description of the establishment with full address]

I, Shri/Shrimati/Kumari .........................................…………………………..

[Name in full here]

whose particulars are given in the statement below, hereby nominate the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid and direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).

2. I hereby certify that the person(s) mentioned is a/are member(s) of my family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972.

3. I hereby declare that I have no family within the meaning of clause (h) of section (2) of the said Act. 4.

a. My father/mother/parents is/are not dependant on me.

b. My husband’s father/mother/parents is/are not dependant on my husband.

5. I have excluded my husband from my family by a notice dated the ................ to the Controlling Authority in terms of the proviso to clause (h) of section 2 of the said Act.

6. Nomination made herein invalidates my previous nomination.

Nominee(s)

Name in full with full address of nominee(s)

Relationship with the employee

Age of nominee

Proportion by which the gratuity will be shared

1. 2. 3. so on.

Statement

1. Name of employee in full. 2. Sex. 3. Religion. 4. Whether unmarried/married/widow/widower. 5. Department/Branch/Section where employed. 6. Post held with Ticket or Serial No., if any. 7. Date of appointment. 8. Permanent address. Village ................... Thana ................... Sub‐division ................... Post Office ................... District ................... State ................... Place............................ Signature/Thumb impression Date............................. of the employee



Declaration by witnesses

Nomination signed/thumb impressed before me.

Name in full and full Signature of witnesses. address of witnesses.

1. 1. 2. 2.

Place............................

Date.............................

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer’s Reference No., if any.

Signature of the employer/ officer authorised

Designation

Date............................. Name and address of the establishment or rubber stamp thereof.

Acknowledgement by the employee

Received the duplicate copy of nomination in Form ‘F’ filed by me and duly certified by the employer.

Date............................. Signature of the employee



C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ O 1 0

FORM ‐ G

[See Sub‐Rule (3) of Rule 6]

Fresh Nomination To

[Give here name or description of the establishment with full Address]

I, Shri/Shrimati ..............................................................................................................

[Name in full here]

whose particulars are given in the statement below, have acquired a family within the meaning of clause (h) of section (2) of the Payment of Gratuity Act, 1972 with effect from the ...................... [date here] in the manner indicated below and therefore nominate afresh the person(s) mentioned below to receive the gratuity payable after my death as also the gratuity standing to my credit in the event of my death before that amount has become payable, or having become payable has not been paid direct that the said amount of gratuity shall be paid in proportion indicated against the name(s) of the nominee(s).

2. I hereby certify the person(s) nominated is a/are member(s) of my family within the meaning of clause (h) of section 2 of the said Act.

3. a. My father/mother/parents is/are not dependant on me. b. My husband’s father/mother/parents is/are not dependant on my husband.

4. I have excluded my husband from my family by a notice dated the ..................... to the controlling authority in

terms of the proviso to clause (h) of section 2 of the said Act.

Nominee(s)

Name in full with full address of nominee(s)

Relationship with the employee

Age of nominee

Proportion by which the gratuity will be shared

1. 2. 3. 4. so on.

Manner of acquiring a “family”

[Here give details as to how a family was acquired, i.e., whether by marriage or parents being rendered dependant or through other process like adoption].

Statement 1. Name of the employee in full. 2. Sex. 3. Religion. 4. Whether unmarried/married/widow/widower. 5. Department/Branch/Section where employed.



6. Post held with Ticket No. or Serial No., if any. 7. Date of appointment. 8. Permanent address. Village .................. Thana .................. Sub‐division .................. Post Office .................. District .................. State .................. Place............................ Signature/Thumb impression Date............................. of the employee.

Declaration by witnesses Fresh nomination signed/thumb impressed before me. Name in full and full Signature of witnesses. addresses of witnesses. 1. 1. 2. 2.

Place............................. Date.............................

Certificate by the employer

Certified that the particulars of the above nomination have been verified and recorded in this establishment.

Employer’s reference No., if any. Signature of the employer/ officer authorised Designation

Date............................. Name and address of the establishment or rubber stamp thereof.

Acknowledgement by the employee

Received the duplicate copy of the nomination in Form .................. filed by me on.................. duly certified by the employer.

Date............................. Signature of the employer




FORM‐H [See Sub‐Rule (4) of Rule 6]

Modification of Nomination To [Give here name or description of the establishment with full address]

I, Shri/Shrimati/Kumari .........................................................................................

[Name in full here]

whose particulars are given in the statement below, hereby give notice that the nomination filed by me on …………..[date] and recorded under your reference No. .......... dated .................. shall stand modified in the following manner:

[Here give details of the modifications intended]

Statement 1. Name of the employee in full. 2. Sex. 3. Religion. 4. Whether unmarried/married/widow/widower. 5. Department/Branch/Section where employed. 6. Post held with Ticket No. or Serial No., if any. 7. Date of appointment. 8. Address in full.

Place............................. Signature/Thumb impression Date............................. of the employee.

Declaration by witnesses Modification of nomination signed/thumb impressed before me. Name in full and full Signature of witnesses. address of witnesses. 1. 1. 2. 2. Place............................. Date.............................

Certificate by the employer Certified that the above modification have been recorded. Employer’s reference No., if any.

Signature of the employer/officer authorised Designation



Name and address of the establishment or rubber stamp thereof.

Acknowledgement by the employee Received the duplicate copy of the notice for modification in Form ‘H’ filed by me on ................. duly certified by

the employer. Date............................. Signature of the employee

Note: Strike out the words not applicable.



FORM ‐I [See Sub‐Rule (1) of Rule 7]

Application of Gratuity by an Employee To

[Give here name or description of the establishment with full address] Sir/Gentlemen,

I beg to apply for payment of gratuity to which I am entitled under sub‐section (1) of section 4 of the Payment of Gratuity Act, 1972 on account of my superannuation/retirement/resignation after completion of not less than five years of continuous service/ total disablement due to accident/total disablement due to disease with effect from the .................. Necessary particulars relating to my appointment in the establishment are given in the statement below:

Statement 1. Name in full. 2. Address in full. 3. Department/Branch/Section where last employed. 4. Post held with Ticket No. or Serial No., if any. 5. Date of appointment. 6. Date and cause of termination of service. 7. Total period of service. 8. Amount of wages last drawn. 9. Amount of gratuity claimed. I was rendered totally disabled as a result of

[Here give the details of the nature of disease or accident] The evidences/witnesses in support of my total disablement are as follows:

[Here give details] Payment may please be made in cash/open or crossed bank cheque.

As the amount of gratuity payable is less than rupees one thousand, I shall request you to arrange for payment of the sum due to me by Postal Money Order at the address mentioned above after deducting postal money order commission there from.

Yours faithfully,

Signature/Thumb impression of the applicant employee.

Place............................ Date.............................

Note.—1. Strike out the words not applicable. 2. Strike out paragraph or paragraphs not applicable.



FORM ‐J [See Sub‐Rule (2) of Rule 7]

Application for Gratuity by a Nominee To

[Give here the name or description of the establishment with full address] Sir/Gentlemen,

I beg to apply for payment of gratuity to which I am entitled under sub‐section (1) of section 4 of the Payment of Gratuity Act, 1972 as a nominee of late.....................................................................................

[name of the employee]

who was an employee of your …………….establishment and died on the .................. The gratuity is payable on account of the death of the aforesaid employee while in service/superannuation of the aforesaid employee on .................. retirement of/resignation of the aforesaid employee on .................. after completion of .................. years of service/total disablement of the aforesaid employee due to accident or disease while in service with effect from the .................. Necessary particulars relating to my claim given in the statement below:

Statement 1. Name of applicant nominee. 2. Address in full of the applicant nominee. 3. Marital status of the applicant nominee

(unmarried/married/widow/widower) 4. Name in full of the employee. 5. Marital status of employee. 6. Relationship of the nominee with employee. 7. Total period of service of the employee. 8. Date of appointment of the employee. 9. Date and cause of termination of service of the employee. 10. Department/Branch/Section where the employee last worked. 11. Post last held by the employee with Ticket or Serial No., if any. 12. Total wages last drawn by the employee. 13. Date of death and evidence/witness as proof of death of the employee. 14. Reference No. of recorded nomination, if available. 15. Total gratuity payable to the employee. 16. Share of gratuity claimed.

2. I declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and belief.

3. Payment may please be made in cash/crossed or open bank cheque. 4. As the amount payable is less than rupees one thousand, I shall request you to arrange for payment of the sum

due to me by Postal Money Order at the address mentioned above after deducting Postal Money Order commission there from.

Yours faithfully,

Signature/Thumb impression of the applicant employee.

Place............................



Date.............................

Note.—1. Strike out the words not applicable.

FORM ‐ K [See Sub‐Rule (3) of Rule 7]

Application for Gratuity by a Legal Heir To [Give here the name or description of the establishment with full address] Sir/Gentlemen, I beg to apply for payment of gratuity to which I am entitled under sub‐section (1) of section 4 of the Payment of

Gratuity Act, 1972 as a legal heir of late .......................................................................................................

[name of the employee]

who was an employee of your …………………….establishment and died on the ....... without making any nomination. The gratuity is payable on account of the death of the aforesaid employee while in service/ superannuation of the aforesaid employee on the .................. retirement or resignation of the aforesaid employee on the .................. after completion of .................. years of service/total disablement of the aforesaid employee due to accident or disease while in service with effect from the .................. Necessary particulars relating to my claim are given in the statement below:

Statement 1. Name of applicant legal heir. 2. Address in full of applicant legal heir. 3. Marital status of the applicant legal heir (unmarried/married/widow/widower) 4. Name in full of the employee. 5. Relationship of the applicant with the employee. 6. Religion of both the applicant and the employee. 7. Date of appointment and total period of service of the employee. 8. Department/Branch/Section where the employee worked last. 9. Post last held by the employee with Ticket or Serial No., if any. 10. Total wages last drawn by the employee. 11. Date and cause of termination of service of the employee (death or otherwise). 12. Date of death of the employee and evidence/witness in support thereof. 13. Total gratuity payable to the employee. 14. Percentage of the gratuity claimed. 15. Basis of the claim and evidence/witness in support thereof.

2. I declare that the particulars mentioned in the above statement are true and correct to the best of my knowledge and belief.

3. Payment may please be made in cash/open or crossed bank cheque. 4. As the amount payable is less than rupees one thousand, I shall request you to arrange for payment of the sum

due to me by Postal Money Order at the address mentioned above, after deducting Postal Money Order commission there from.

Yours faithfully, Signature/Thumb impression of applicant legal heir.

Place............................

Date.............................



Note.—Strike out the words not applicable.

FORM ‐ L [See Clause (i) of Sub‐Rule (1) of Rule 8]

Notice for Payment of Gratuity To

[Name and address of the applicant employee/nominee/legal heir]

1. You are hereby informed as required under clause (i) of sub‐rule (1) of rule 8 of the Payment of Gratuity (Central) Rules, 1972 that a sum of Rs. ....... (Rupees ...................) is payable to you as gratuity/as your share of gratuity in terms of nomination made by .................. on .................. and .................. recorded in this .................. as a legal heir of .................. an employee of this .................. establishment.

2. Please call at ...................................................................................on .........................

(Here specify place) (date)

at…………………………………………….. for collecting your payment in cash/open or crossed cheque.

3. Amount payable shall be sent to you by Postal Money Order at the address given in your application after deducting the Postal Money Order commission, as desired by you.

Brief statement of calculation

1. Total period of service of the employee concerned: ............. years ....... months. 2. Wages Last drawn. 3. Proportion of the admissible gratuity payable in terms of nomination/as a legal heir. 4. Amount payable.

Signature of the employer/

Authorised Officer

Place.............................

Date.............................

Name or description of establishment or rubber stamp thereof.

Copy to : The Controlling Authority:

Note.—Strike out the words not applicable.



FORM ‐ M [See Clause (ii) of Sub‐Rule (1) of Rule 8]

Notice Rejecting Claim for Payment of Gratuity To

[Name and address of the applicant employee/nominee/legal heir] You are hereby informed as required under Clause (ii) of Sub‐Rule (i) of Rule 8 of the Payment of Gratuity

(Central) Rules, 1972 that your claim for payment of gratuity as indicated on your application in Form ........ under the said rules is not admissible for the reasons stated below:

Reasons [Here specify the reasons]

Signature of the employer/ Authorised Officer.

Place............................ Date.............................

Name or description of establishment or rubber stamp thereof.

Copy to : The Controlling Authority.




FORM ‐N [See Sub‐Rule (i) of Rule 10]

Application for Direction

Before the controlling authority under the Payment of Gratuity Act, 1972.

Application No…………………………. Date……………………………………….

BETWEEN

[Name in full of the applicant with full address]

AND

[Name in full of the employer concerned with full address]

1. The applicant is an employee of the above‐mentioned employer/a nominee of late ..................... an employee of the above mentioned employer/a legal heir of late ..................... an employee of the above‐mentioned employer, and is entitled to payment of gratuity under section 4 of the Payment of Gratuity Act, 1972, on account of his own/ aforesaid employee’s superannuation on ............................... [date] /his own retirement/aforesaid employee’s resignation on .......................... [date] after completion of ..................... years of continuous service/his own/aforesaid employee’s total disablement with effect from .............[date] due to accident/disease/death of the aforesaid employee on .....................

2. The applicant submitted an application under Rule ..................... of the Payment ofGratuity Act, 1972 on the ..................... but the above‐mentioned employer refused to entertain it/issued a notice dated the ..................... under clause .......of sub‐rule of rule ................ offering an amount of gratuity which is less than my due/issued a notice dated the..................... under Clause .................... of Sub‐Rule ........ of Rule ........ rejecting my eligibility to payment of gratuity. The duplicate copy of the said notice is enclosed.

3. The applicant submits that there is a dispute on the matter. [Specify the dispute]

4. The applicant furnishes the necessary particulars in the annexure hereto and prays that the Controlling Authority may be pleased to determine the amount of gratuity payable to the petitioner and direct the above mentioned employer to pay the same to the petitioner.

5. The applicant declares that the particulars furnished in the annexure hereto are true and correct to the best of his knowledge and belief.

Date Signature of the applicant/

Thumb impression of the applicant.

ANNEXURE

1. Name in full of applicant with full address. 2. Basis of claim : [Death/Superannuation/Retirement/Resignation/

Disablement of employee]. 3. Name and address in full of the employee. 4. Marital status of the employee

(unmarried/married/widow/widower) 5. Name and address in full of the employer. 6. Department/Branch/Section where the employee was employed [if known]. 7. Post held by the employee with Ticket or Serial No., if any [if known].



8. Date of appointment of the employee [if known]. 9. Date and cause of termination of service of the employee. [superannuation/

retirement/resignation/disablement/death] 10. Total period of service by the employee. 11. Wages last drawn by the employee. 12. If the employee is dead, date and cause thereof. 13. Evidence/witness in support of death of the employee. 14. If a nominee, No. and date of recording of nomination with the employer. 15. Evidence/witness in support of being a legal heir, if a legal heir. 16. Total gratuity payable to the employee [if known]. 17. Percentage of gratuity payable to the applicant as a nominee/legal heir. 18. Amount of gratuity claimed by the applicant.

Place............................ Signature/Thumb impression of the applicant.

Date.............................




FORM‐O [See Sub‐Rule (1) of Rule 11]

Notice for Appearance before the Controlling Authority From: The Controlling Authority under the Payment of Gratuity Act, 1972. To [Name and address of the employee/applicant]

Whereas Shri ....................., an employee under you/a nominee(s) legal heir(s) of Shri .....................an employee under the above‐mentioned employer, has/have filed an application under sub‐rule (1) of rule 10 of the Payment of Gratuity (Central) Rules, 1972 alleging that ..................

[A copy of the said application is enclosed] Now, therefore, you are hereby called upon to appear before me at ..................... [place] either personally or through a person duly authorised in this behalf for the purpose of answering all material questions relating to the application on the ................ day of ............... 20..... at .......... o’clock in the forenoon/afternoon in support of/to answer the allegation; and as the day fixed for your appearance is appointed for final disposal of the application, you must be prepared to produce on that day all the witnesses upon whose evidence, and the documents upon which you intend to rely in support of your allegation/defence. Take notice that in default of your appearance on the day before mentioned the application will be dismissed/heard and determined in your absence. Give under my hand and seal, this ............... day of ............... 20 ............................

Controlling Authority

Note : Strike out the words and paragraphs not applicable.



FORM ‐ P (See Rule 14)

Summons Before the Controlling Authority under the Payment of Gratuity Act, 1972. To [Name and address] Whereas your attendance is required to give evidence/you are required to produce the documents mentioned in

this list below, on behalf of .......... in the case arising out of the claim for gratuity by..................... from ..................... and referred to this Authority by an application under section 7 of the Payment of Gratuity Act, 1972, you are hereby summoned to appear personally before this Authority on the .......... day of ............20 ..... at .......... o’clock in the forenoon/afternoon and to bring with you (or to send to this Authority) the said documents.

List of Documents

1.

2.

3. So no

Controlling Authority

Dated this ............... day of .............. 20 .....

Notes.—

1. The portion not applicable to be deleted. 2. The summons shall be issued in duplicate. The duplicate is to be signed and returned by the person served

before the date fixed. 3. In case summons is issued only for producing a document and not to give evidence, it will be sufficient

compliance to the summons if the documents are caused to be produced before the controlling authority on the day and hour fixed for the purpose.



FORM ‐ Q [See Sub‐Rule (1) of Rule 19]

Particulars of Application under Section 7 1. Serial No. 2. Date of the Application. 3. Name and address of the applicant. 4. Name and address of the employer. 5. Amount of gratuity claimed. 6. Dates of hearing. 7. Findings with date. 8. Amount awarded. 9. Cost, if any, awarded. 10. Date of notice issued for payment of gratuity. 11. Date of appeal, if any. 12. Decision of the appellate authority. 13. Date of issue of Final Notice for payment of gratuity. 14. Date of payment of gratuity by Employer with mode of payment. 15. Date of Receipt of application for recovery of Gratuity. 16. Date of Issue of Recovery Certificate. 17. Date of Recovery. 18. Other remarks. 19. Signed. 20. Date.



FORM ‐ R (See Rule 17)

Notice for Payment of Gratuity To

[Name and address of employer] Whereas Shri/Smt/Kumari ..................... of .......................... (address) an [employee under you/a nominee(s) legal heir(s) of late ..................... and employee under you, filed an application under section 7 of the Payment of Gratuity Act, 1972 before me; And whereas the application was heard in your presence on and after the hearing I have come to the finding that the said Shri/Smt./ Kumari ..................... is entitled to a payment of Rs ...................... as gratuity under the Payment of Gratuity Act, 1972; Now, therefore, I hereby direct to pay the said sum of Rs ........................... to Shri/Smt./Kumari ..................... within thirty days of the receipt of this notice with intimation thereof to me. Given under my hand and seal, this ............. day of ............ 20 ......

Controlling Authority Copy to :

(Applicant under Rule) He is advised to contact the employer for collecting payment.

Note.—The portion not applicable to be deleted.



FORM ‐S [See Sub‐Rule (5) of Rule 18]

Notice for Payment of Gratuity as Determined by Appellate Authority

To [Name and address of employer]

Whereas a notice was given to you on ...................... Form ‘R’ requiring you to make a payment of Rs ................. to Shri/Smt./Kumari .................... as gratuity under the Payment of Gratuity Act, 1972; Whereas you/the applicant went in appeal before the appellate authority, who has decided that an amount of Rs ................ is due to be paid to Shri/Smt./Kumari ..................... as gratuity due under the Payment of Gratuity Act, 1972; Now, therefore, I hereby direct you to pay the said sum of Rs ............... to Shri/Smt./Kumari ..................... within 30 days of the receipt of this notice with an intimation thereof to me. Given under my hand and seal, this ........... day of ........... 20.....

Controlling Authority. Copy to:

1. The Applicant. He is advised to contact the employer for collecting payment.

2. The Appellate Authority.

Note.— The portion not applicable to be deleted.



FORM ‐T (See Rule 19)

Application for Recovery of Gratuity Before the Controlling Authority under the Payment of Gratuity Act, 1972. Application No............... Date .......................

BETWEEN

[Name in full of the applicant with address] AND

[Name in full of the employer with full address] 1. The applicant is an employee of the above‐mentioned employer/a nominee of late................. an employee of the

above mentioned employer/a legal heir of late............., an employee of the above mentioned employer, and you were pleased to direct the said employer in your notice dated the ................. under Rule ................ of the Payment of Gratuity (Central) Rules, 1972 for payment of a sum of Rs ............. as gratuity payable under the Payment of Gratuity Act, 1972.

2. The applicant submits that the said employer failed to pay the said amount of gratuity to me as directed by you although I approached him for payment.

3. The applicant therefore prays that a certificate may be issued under section ............. of the said Act for the recovery of the said sum of Rs.................. due to me as gratuity in terms of your direction.

Signature/Thumb impression of the applicant

Place............................

Date.............................

Note : Strike out the words and paragraphs not applicable.

Forms under PAYMENT OF BONUS RULES,1975

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ P 1

Forms under

PAYMENT OF BONUS RULES,1975



INDEX FORM A

Computation of the Allocable Surplus under Section 2(4)

FORM B

Set‐on and Set‐off of Allocable Surplus under Section 15

FORM C Bonus Paid to Employees for the Accounting Year

FORM D

Annual Return—Bonus Paid to Employees for The Accounting Year



FORM A [See Rule 4(1)]

Computation of the Allocable Surplus under Section 2(4)

Name of the establishment................................... Accounting year ending on the................................................

Sums deducted from gross profit Direct taxes section 6(c)

Further sums as are specified under the Third Schedule to the Act Gross profit for the

Accounting year Rs.

Depreciation under section 6(a)

Development rebate or Development allowance

section 6(b)

1 2 3 4 5

Total of sums deducted under

Column 2,3,4, and 5 Available surplus for the accounting year

(Column 1 minus Column 6) Amount of allocable surplus

† 67% (*60% of Column 7)

6 7 8

† Section 2 (4)(a) * Section 2 (4) (b)



FORM B [See Rule 4(b)]

Set‐on and Set‐off of Allocable Surplus under Section 15

Accounting year Amount allocable as bonus (in Rs.)

Amount payable as bonus (in Rs.)

Amount of set‐on or set‐off (in Rs.)

Total set‐on or set‐off carried forward

(in Rs.)

1 2 3 4 5



FORM C [See Rule 4(c)]

Bonus Paid to Employees for the Accounting Year Ending on the...................... Name of the establishment...........................................

No. of working days in the year................................

Sl. No.

Name of the

employee

Father’s name

Whether he has completed 15 years

of age at the beginning of the accounting year

Designation No. of days worked in the year

Total salary or wage in respect of the accounting

year

Amount of bonus payable under section 10 or section 11 as the case may be

1 2 3 4 5 6 7 8

Deductions Total sum deducted under Columns, 9 10,10A and 11

Net amount payable (Column 8 minus Column 12)

Amount actually paid

Date on which paid

Signature/ Thumb impression of the employee

Puja bonus or other customary bonus during the accounting year

Interim bonus or bonus paid advance

Amount of Income‐tax deducted

Deduction on account of financial loss, if any, caused by misconduct of the employee

9 10 1[10A] 11 12 13 14 15 16



FORM D [See Rule 5]

Annual Return—Bonus Paid to Employees for the Accounting Year Ending on the......................

1. Name of the establishment and its complete postal address: 2. Name of industry: 3. Name of the employer: 4. Total number of employees: 5. Number of employees benefited by bonus payments:

Total amount payable as bonus under section 10 or 11 of the Payment of Bonus Act, 1965 as the case may be

Settlement, if any, reached under section 18(1) of 12(3)

of the Industrial Disputes Act, 1947 with date

Percentage of bonus declared to be paid

(1) (2) (3)

Total amount of bonus actually paid

Date on which payment made

Whether bonus has been paid to all the employees, if not, reasons for non‐payment

Remark

(4) (5) (6) (7)

Signature of the employer of his agent

Forms under EQUAL REMUNERATION RULES, 1976

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ Q 1

Forms under the

EQUAL REMUNERATION RULES, 1976



INDEX

Form A Complaint under Clause (a) of Sub Section (I) of Section 7 of the Equal

Remuneration Act ,1976 ( 25 of 1976)

Form B Claim under Clause (b) of Section (I) of Section 7 of the Equal Remuneration Act, 1976 (25 of 1976)

Form C Form of Authority in Favor of Legal Practitioner or any Official of a Registered Trade Union

Form D Register to be Maintained by the Employer under Rule (6) of the Equal Remuneration Rules, 1976



FORM A (To be submitted in Triplicate)

[See Rule 3(1)] Complaint under Clause (a) of Sub Section (I) of Section

7 of the Equal Remuneration Act ,1976 ( 25 of 1976) To The Authority appointed under sub‐section I of section 7 …………………………………………………………………………………. (Address) A…………………………………………………………………Complainant(s)

Full address Versus

B. ……………………………………………………………………Opposite Party

Full address The complainant(s) begs/beg to complain that the opposite party has been guilty of contraventions of the provisions of Equal Remuneration Act, 1976 (25 of 1976) as show below: ‐ (Here set out briefly the particulars showing the manner in which the alleged contravention(s) has/have taken place and the grounds supporting the complaint.) The complainant(s) accordingly prays/ pray that the Authority ___________________________may be pleased to decide the complaint set out above and pass such order or orders thereon as it may deem fit and proper. The number of copies of the complaint (along with annexure) as required under sub‐rule (I) of Rule 3 of the Equal Remuneration Rules, 1976 are submitted herewith. The complainant(s) does/ do solemnly declare that the facts stated in this complaint are true to the best of his/her/their knowledge, belief and information. Signature(s)/ Thumb impressions of the complainant(s). * I have been duly authorized in writing by ____________________ [ here insert the name of the worker(s), to appear and act on his/her/their behalf.

Signature of the legal practitioner / official of a registered Trade Union duly authorized

Station Date * Strike out this portion if applicable



FORM B (To be submitted in Triplicate)

[See Rule 4(1)] Claim under Clause (b) of Section (I) of Section 7 of the Equal Remuneration Act, 1976 (25 of 1976)

To The Authority appointed under sub‐section I of section 7 …………………………………………………………………………………. (Address) A…………………………………………………………………Petitioner(s)

Full address Versus

B. ……………………………………………………………………Opposite Party Full address

The petitioner(s) above named states/ state as follows:‐

1) The petitioner was/were/ is/ are employed from ______________ to______________ as ___________________ (category) in_____________________ (name of the establishment) of Shri / Messrs__________________ ( name of the employer and address).

2) The opposite party is the employer within the meaning of clause (c) of Section 2 of the Equal Remuneration Act, 1976 ( 25 of 1976).

3) The petitioner(s) was/were/has/have not been paid wages at rates equal to those of workers of the opposite sex for the same work or work of a similar nature for the period from___________________ to____________________

4) The petitioner(s) was/were/has/have been paid wages at the rate of ______________ weheras workers of the opposite sex for the same work or work of a similar nature were paid/ have been paid at the rate of ____________________ during the said period.

5) The petitioner(s) estimates/ estimate the value of relief sought by him/them at Rs________________ [ Rupees________________________________( in words)

6) The petitioner(s), therefore, prays/pray that the Authority may be pleased to decide the claim set out above and pass such order or orders thereon as it may deem fit and proper.

7) The petitioner(s) begs/beg leave to amend or add to or make alternations in the petition, if and when necessary, with permission of Authority.

The petitioner(s) does/do solemnly declare that the facts stated in this petition are true to the best of his/her/their knowledge, belief and information.

Signature / thumb impression(s) of the petitioner(s)



* I have been duly authorized in writing by ________________________ [ here insert the name of worker(s) ] to appear and act on his/her/their behalf.

Signature of the legal practitioner / official of a registered Trade Union duly authorized

Station Date * Strike out this portion if inapplicable



FORM C [See Rule 5]

Form of Authority in favor of Legal Practitioner or any

Official of a Registered Trade Union I/we hereby authorize Shri/ Shrimati/ Kumari* ___________________ a legal practitioner/ an official of___________________________which is a registered Trade Union to appear and act on my/our behalf, under * sub‐rule (3) of Rule 3/ sub rule (3) of Rule 4 in respect of the * complaint / claim against________________________ ( mention name of employer) on account of _____________________ ( mention violation of the Act).

Signature / thumb impression(s) of the worker(s)

Station Date Witness (1)……… (2)……… (3)………. I accept the authorization.

* Legal Practitioner/ Official of a registered Trade Union

Station Date * Strike out this portion if inapplicable



FORM D [See Rule 6]

Register to be Maintained by the Employer under Rule (6) of The Equal

Remuneration Rules, 1976 Name of the establishment with full address ___________________________________ Total number of workers employed ____________________________________________ Total number of men workers employed ____________________________________________ Total number of women workers employed ____________________________________________

Components of remuneration

Category of w

orkers

Brief d

escriptio

n of

work

No. of m

en employ

ed

No. of w

omen

employ

ed

Rate of rem

uneration

paid

Basic wage or salary

Dearness A

llowan

ce

Hou

se Rent A

llowan

ce

Other Allo

wan

ce

Cash value of

concession

al su

pply of

essential com

mod

ities

1 2 3 4 5 6 7 8 9 10

Forms under EMPLOYMENT EXCHANGE (COMPULSORY NOTIFICATION OF VACANCIES) RULES, 1960

C o m p i l e d b y P o w e r H R F o r u m P a g e - R 1

Forms under

EMPLOYMENT EXCHANGE (COMPULSORY NOTIFICATION OF VACANCIES) RULES, 1960



INDEX FORM AND MANNER OF NOTIFICATION OF VACANCIES

Requisition Form to be Used When Calling for Applicants from Employment Exchanges.

FORM ER‐I Quarterly Return to be Submitted to the Local Employment Exchange

FORM ER‐II

Occupational Return to be Submitted to the Local Employment Exchanges Once in Two Years



Requisition Form to be Used When Calling for Applicants from Employment Exchanges.

(Separate form to be used for each type of posts) 1. Name, address and Telephone No. (if any)

of the employer ______________________________ 2. Name, designation and Telephone No. (if any) of the indenting officer ______________________________ 3. Nature of vacancy:

a) Designation of the post(s) to be filled ______________________________ b) Description of duties ______________________________ c) Qualifications required: ______________________________

*For priority categories For (applicable for Central others

Government posts only) i. (Essential _______________ ____________ ii. Desirable _______________ ____________

d) Age limits, if any _______________ ____________ e) Whether women are eligible? _______________ ____________

4. Number of posts to be filled duration wise Number of posts Duration

a) Permanent _______________ ____________ b) Temporary: _______________ ____________

i. Less than 3 months _______________ ____________ ii. Between 3 months and one year _______________ ____________ iii. Likely to be continued beyond one year _______________ ____________

5. Whether there is any obligation or arrangement for giving preference to any category of persons such as Scheduled

Caste, Scheduled Tribe, Ex‐Servicemen and Physically Handicapped persons in filling up the vacancies and, if so, the number of vacancies to be filled by such categories of persons‐

Categories Number of vacancies to be Filled Total *By Priority candidates (applicable for

Central Government posts only) a) Scheduled Caste ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

b) Scheduled Tribe ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

c) Ex‐servicemen ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

d) Physically Handicapped ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

e) Others ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐



6. Pay and allowances _______________ ____________ 7. Place of work (Name of the town/

village and district in which it is situated) _______________ ____________ 8. Probable date by which the vacancy will be filled _______________ ____________ 9. Particulars regarding interview/test of applicants:

a) Date of interview/test: _______________ ____________ b) Time of interview/test: _______________ ____________ c) Place of interview/test: _______________ ____________ d) Name, designation, address and telephone

number, (if any) of the Officer to whom applicants should report _______________ ____________ 10. Any other relevant information _______________ ____________ *Certified that while placing this demand, the instructions connected with the orders on communal representation

in the services have been strictly followed with due regard to the roster maintained in accordance with these orders (to be given only by all the Central Government Offices/Establishments/Undertakings etc. on whom reservation orders are applicable).

Signature of the Head of Office:

Date:— *Delete if not applicable];



FORM ER‐I Quarterly Return to be Submitted to the Local Employment Exchange for the Quarter

Ended . . ……………… The following information is required under the Employment Exchanges (Compulsory Notification of Vacancies) Rules, 1960 to assist in evaluating trends in employment and for action to correct imbalances between labour supply and demand. Name and address of the employer Head Office Whether Branch Office. Nature of business/principal activity ............................................... 1. a. Employment Total number of persons including working proprietors/partners/commission agents/contingent paid and contractual workers, on the pay rolls of the establishment excluding part‐time workers and apprentices. (The figures should include every person whose wage or salary is paid by the establishment).

On the last working day of the previous quarter On the last working day of the quarter under report

Men Women

Total b. Please indicate the main reasons for any increase or decrease in employment if the increase or decrease is more

than 5 per cent during the quarter................ Note.—Establishments are reminded of their obligation under the Employment Exchanges (Compulsory Notification of

Vacancies) Act for notifying to Employment Exchanges details of vacancies specified under the Act, before they are filled.

2. Vacancies: Vacancies carrying total emoluments of Rs 60 or over per month and of over 3 monthʹs duration. 2.

a) Number of vacancies occurred and notified during the quarter and the number filled during the quarter. Number of vacancies which come within the purview of the Act

Occurred Notified Filled Source (describe the source from which filled) Local

Employment Exchange

Central Employment Exchange



(1) (2) (3) (4) (5)

b) Reasons for not notifying all vacancies occurred during the quarter under report vide 2(a) above. 3. Manpower shortages

Vacancies/posts unfilled because of shortage of suitable applicants. Name of the occupation or designation of the posts

Number of unfilled vacancies/posts

essential qualifications prescribed

Essential experience

experience not necessary

(1) (2) (3) (4)

Please list any other occupations for which this establishment had recently any difficulty in obtaining suitable applicants.

Signature of employer Employment Exchange, ……………………………….. ……………………………….. Note.—This return shall relate to quarters ending 31st March/30th June/30th September and 31st December and shall be

rendered to the local Employment Exchange within 30 days after the end of the quarter concerned.



FORM ER‐II

Occupational Return to be Submitted to the Local Employment Exchanges Once in Two Years (On a Date to be Specified by Notification in the Official Gazette)

[Vide the Employment Exchanges (Compulsory Notification of Vacancies) Rules, 1960]

Name and address of the employer. Nature of business. (Please describe what the establishment makes or does as its principal activity) 1. Total number of persons on the pay rolls of the establishment on (specified date). ......... (This figure should include every person whose wage or salary is paid by the establishment.) 2. Occupational classification of all employees as given in Item 1 above. (Please give below the number of employees

in each occupation separately.)

Occupation Number of employees (1) (2) (3) (4) (5)

Use exact terms such as engineer (Mechanical); teacher (domestic/science); officer on special duty (actuary); assistant director (metallurgist); scientific assistant (chemist); research officer (economist); instructor (carpenter); supervisor (tailor); fitter (internal combustion engine); inspector (sanitary); superintendent (office); apprentice (electrician).

Men Women Total Please give as far as possible approximate number of vacancies in each occupation you are likely to fill during the next calendar year due to retirement, expansion or reorganization

…………………………………….. ………….

…………… ………

……………………..

…………………………………….. …………. …………… ……… …………………….. Total Dated: Signature of employer. To, The Employment Exchange, (Please fill in here the address of your Local Employment Exchange) Note.—Total of Column (4) under Item 2 should correspond to the figure given against Item 2.

Forms under APPRENTICESHIP RULES, 1992

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ S 1

Forms under

APPRENTICESHIP RULES, 1992



INDEX FORMAT 1

Model Contract of Apprenticeship Training for Major/Minor Apprentices

FORMAT 1A

Intimation Regarding Engagement of Apprentices and Forwarding their Contracts for Registration

FORMAT 2

Proforma of Work Diary

FORMAT 3

Application Form for Appearing at the All India Trade Test Under The Apprentices Act, 1961 as Regular Candidate

FORMAT 3A

Forwarding of Application Forms of Apprentices for All India Trade Test

FORMAT 4

Eligibility Certificate for Appearing at All India Trade Test along with Assessment of the Apprentices

FORM APPRENTICESHIP 1

Submission of Half Yearly Returns

APPRENTICESHIP TRAINING SCHEME 1

Submission of Half‐Yearly Returns

APPRENTICESHIP TRAINING SCHEME 2 (FOR RDAT)

Submission of Half‐Yearly Returns:

APPRENTICESHIP TRAINING SCHEME 3 (STATE/UNION TERRITORY)



To be Submitted within Ten Days from the Date of Engagement of Apprentices Applicable only to Graduate or Technician or Technician (Vocational) Apprentices

FORM APPENTICESHIP 3

Record of Progress of Apprentice to be Submitted once in a Quarter in Respect of Graduate or Technician or Technician (Vocational) Apprentices

\



FORMAT 1 (See rule 14)

Model Contract of Apprenticeship Training

for Major/Minor Apprentices (To be prepared in Triplicate)

1. Name and address of the Establishment................................

Telephone No........................ Fax No............................ Telegram................................ E‐Mail Address..............

2. (a) Name of Apprentice (Block Letters)................................... (b) Father’s/Mother’s/Husband’s Name.................................

3. Correspondence Address............................................................

4. Date of birth...................................................................................

5. (a) Date of execution of contract:.............................................. (b) Age on the date of execution of contract.........................

6. Whether belongs to Scheduled Caste/Scheduled Tribe Physically Handicapped/Other Backward Class or Minority Community. If so, please mention the category.................... .................................................................

7. Present Qualification:— a. General Education:................................................................. b. Technical:..................................................................................

Name of the Trade/Course:............................................. Duration of Training:......................................................... From...........to....... Name of the Institute:........................................................ Name of the Board/Council:............................................

8. Name of the Apprenticeship Trade:..........................................

9. a. Duration of Apprenticeship Training:............................... b. Period of Apprenticeship:..............................................................years......months

Photograph of Apprentice



10. Rates of Stipend From.........to.......... First Year Rs.......p.m Second Year Rs.......p.m Third Year Rs......p.m Fourth Year Rs.......p.m

11. a. Name and Address of Guardian*:...................................... b. Relationship with the Apprentice:......................................

12. Name and Address of the Surety:............................................

13. We, the Employer, Apprentice/Guardian* and the Surety solemnly declare that we have read the Apprentices Act, 1961 and the Apprenticeship Rules, 1992 regarding the contract of Apprenticeship Training including obligations and agree to abide by all the provisions made thereunder. In case of default by either the apprentice or the employer, we agree to compensate the other party as per the provisions of the Apprenticeship Rules, 1992 (Main provisions of the rules may be seen in the Enclosure)

Signature of the Employer with seal

Signature of Apprentice

Signature of Guardian* Signature of Surety

14. Witnesses and their Addresses

1. ............................................. 2. .............................................

15. To be filled in by the Office of the Apprenticeship Adviser:—

i. Registration No..................................................... ii. Date......................................................................... iii. Place.........................................................................

Signature and Seal of the Regional Central ApprenticeshipAdviser/ State Apprenticeship Adviser

*Guardian, in case of minor apprentices



ENCLOSURE TO CONTRACT OF APPRENTICESHIP TRAINNING

Main provisions of the Apprenticeship Rules relating to the contract of Apprenticeship Training

1.

a) The employer shall pay stipend to the trade apprentices at the minimum rates of [As per the provision of rule 11(1) of Apprenticeship Rules, 1992]

Rs. 820 per month during first year.

Rs. 940 per month during second year.

Rs. 1090 per month during third year.

Rs. 1230 per month during fourth year.

Rates are liable to change.

b) The stipend for a particular month shall be paid by the tenth day of the following month. No deduction shall be made from the stipend for the period during which an apprentice remains on casual or medical leave as per provision of the rule. Stipend shall, however, not be paid for the period for which the apprentice remains on extraordinary leave.

2. Where the Contract of Apprenticeship is terminated through failure on the part of the employer in carrying out the terms and conditions of the contract (As notified under the Apprenticeship Rules, 1992), he shall pay to the apprentice compensation as prescribed.

3.

a. In the event of premature termination of Contract of Apprenticeship for failure on the part of apprentice to carry out the terms and conditions of the contract (As notified under the Apprenticeship Rules, 1992), the surety at the request of apprentice hereby guarantees to employer the payment of such amount as determined by the Apprenticeship Adviser as and towards the cost of training.

b. The liability of the surety is limited to Rs. 2,500 (Rupees Two thousand five hundred five hundred only) with interest at twelve per cent. per annum.

4. It shall not be obligatory on the part of employer to offer any employment to the passed out trade apprentice on completion of the period of Apprenticeship Training in his establishment, nor shall it be obligatory on the part of the Apprentice to accept an employment under the employer.



FORMAT 1A Last Date for Forwarding the Contracts for Registration

For the apprentices engaged from 16th January to 15th April : 30th April For the apprentices engaged from 16th April to 15th July : 31st July For the apprentices engaged from 16th July to 15th October : 31st October For the apprentices engaged from 16th October to 15th January : 31st January

Name and Address of Establishment........................................................ Telephone No....................... Telex/Fax No............................. Telegram................................ E‐Mail Address.......................... To The State/Union Territory Apprenticeship Adviser/ The Regional Director of Apprenticeship Training Subject:—Intimation regarding engagement of apprentices and forwarding their contracts for registration Sir/Madam,

Following apprentices have been engaged in our establishment.

Their contracts are forwarded for registration.

Serial Number Name Father’s/Mother’s/Husband’s Name

Trade

We have satisfied ourselves that they fulfill the eligibility criteria as per the provisions of Apprentices Act, 1961 and rules made thereunder. Copies of attested certificates are also enclosed.

Yours Faithfully,

Encl.: As stated above Signature of Employer with

Designation and Seal.



FORMAT 2 Proforma of Work Diary

Name and Address of Establishment...................................... Name of Apprentice.................................................................... Trade............................................................................................... Registration Number................................................................... Serial Number Date (Week) Job/Work done during the week Signature of Supervisor From To

Note.—The work diary should be maintained by the Apprentice and countersigned by his supervisor once a week.



FORMAT 3 Last date for forwarding the application

For the All India Trade Test to be held in April/May : 31st December of previous year

For the All India Trade Test to be held in October/November: 30th June

Application Form for Apprearing at the All India Trade Test to be Held in...........(Month).............(Year) under the Apprentices Act, 1961 as Regular Candidate

1. Name (In block letters)................................................... 2. Father’s/Mother’s/Husband’s Name........................... 3. Mailing Address................................................................ 4. Name and Address of establishment where undergoing Apprenticeship

Training.................................................. 5. Name of the Designated Trade.................................... 6. Contract Registration Number..................................... 7. Period of Apprenticeship Training............................... From .............to............ 8. Whether passed in the subject of Social Studies? If so, please give following details:—

a. All‐India Trade Test for Craftsmen held in......................(Month).................(Year) b. Marks obtained in the subject of Social Studies................. (Please enclose attested copies of certificate) Signature of Employer with seal Signature of Apprentice with Date (For office use in RDAT/SAA)

May be allowed subject to fulfillment of eligibility criteria. If not allowed reason therefore...........................................

Name and Signature of Regional Director/SAA.

Photo of apprentice



FORMAT 3A Last date for forwarding of application For the All India Trade Test to be held in April/May: 31st December of previous year For the All India Trade Test to be held in October/November: 30th June Name and Address of Establishment.......................................... Telephone No................... Telex/Fax No.............. Telegram............................ E‐Mail Address............ To The State/Union Territory Apprenticeship Adviser/ The Regional Director of Apprenticeship Training Subject.—Forwarding of Application Forms of Apprentices for All India Trade Test to be held in .....................(Month)...............(Year) Sir/Madam, The application forms in respect of the following apprentices are forwarded for appearing in All India Trade Test to be held in.....................(Month)...............(Year) Serial Number

Designated Trade Name of the Apprentice

Contract Number Registration

A Demand Draft drawn in favour of ................................is also forwarded towards examination fee of above apprentices @ Rs...................................................

Certified that the progress and attendance of above apprentices are satisfactory.

Date.................... Signature of the Employer with

Designations and Seal.


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ S 1 0

FORMAT 4 Eligibility Certificate for Appearing at All India Trade Test along with Assessment of the Apprentices

Name and Address of Establishment.................................... ........ Telephone No.................... Telex/Fax No............................... Telegram............................. E‐Mail Address............................. Name and Address of Trade Testing Centre................................. All India Trade Test to be held in................. (Month) .......... (Year) Sl No.

Name of the Apprentice

Contract Registration Number

DesignatedTrade

Sessional marks obtained of Maximum Marks

Trade Theory

Workshop Calculation and science

Engineering Drawing

Practical

20 10 20 100

Certified that the above mentioned apprentices fulfill all the stipulated conditions laid down in the enclosure and are eligible to appear in the All India Trade Test to be held in.................(Month).........(Year). The above candidates have been allowed to appear at All India Trade Test by the RDAT/SAA as indicated on their application form enclosed herewith.

Date........................... Signature of Employer with

Designation and Seal

Note.—This information should be sent to the Trade Testing Centre fifteen days prior to the commencement of All India Trade Test.



ENCLOSURE TO ELIGIBILITY CERTIFICATE

Instructions and Guidance to determine eligibility of a candidate for appearing at All India Test under the Apprentices Act, 1961

For determining the eligibility of a candidate to appear at All India Trade Test (AITT), the following points are to be taken into account:— 1. Only those apprentices whose contracts have been registered are eligible for appearing at

AITT. 2. The apprentices who will complete contractual period of training on or before 15th April or

15th October of the calendar year would be eligible for appearing at AITT to be held in April/May or October/November respectively.

3. A candidate who has completed/will be completing Apprenticeship Training on or before the dates as stated at Sl. No. 2 above and has put in the minimum attendance i.e., 200 days per year of apprenticeship training which includes 33 days attendance in Related Instruction Classes or establishments working for five days in a week and 240 days of attendance per year of apprenticeship training which includes 40 days of attendance in R.I. Classes for establishments working for 6 days in a week is eligible for appearing at AITT.

4. A candidate who has completed/will be completing apprenticeship training as stated above but failed/will be failing to acquire minimum attendance for circumstances beyond his control and the employer is satisfied with the grounds for shortfall in attendance and certifies that the apprentice has otherwise completed the full apprenticeship course, he shall be considered as having completed the full period of training and shall be eligible for appearing at AITT.

5. A candidate who has completed/will be completing Apprenticeship Training on or before the dates as stated above but failed/will be failing to put in the minimum period of attendance has not completed the full apprenticeship course, he shall not be considered as having completed the full period of training and the employer shall under sub‐rule (2) of rule 7 of Apprenticeship Rules, 1992 extend his period of training until he completes the full apprenticeship course, and the next test is held if so required by the Apprenticeship Adviser. Similar extension of the period of training may also be allowed in case of those apprentices who having completed but failed in the AITT. An apprentice who fails in the second test shall not be allowed for any extension of the period of training.



FORM APPRENTICESHIP 1 Schedule for submission of Half Yearly Returns

For the half‐year ending June : By 15th of July For the half‐year ending December : By 15th of January

REPORT FOR HALF‐YEAR ENDING................... Name and Address of Establishment..................................................................... Telephone No........................ Telex/Fax No................................................. Telegram................................. E‐Mail Address............................................... Name of the Chief Executive Officer..................................................................... Name and Designation of Officer In charge of Training.................................. Nature of Product/Service Central Public Sector/State Public Sector/Private Sector..................................

Sl No.

Designated Trade

Number of workers other than unskilled workers

Number of apprenticeship seats located SAA/RDAT as per prescribed ratio

Number of apprentices under training

No. of apprentices appeared in All India Trade Test Held in …. (Month)…. Year

No. of apprentices passed in All India Trade Test held in… ( Month) ……. (Year)

No. of passed out apprentices employed by the same employer

Fresher ITI passed out

Total

1 2 3 4 5 6 7 8 9 10

Out of Apprentices undergoing Training Scheduled caste

Scheduled tribe

Other backward classes

Persons with disability Total (14 + 15 +16)

Women Minorities

Visually impaired

Hearing impaired

Orthopedically handicapped

11 12 13 14 15 16 17 18 19 Date...................... Name and Signature of Employer Note.—This information should be sent to the concerned apprenticeship adviser every six month.



APPRENTICESHIP TRAINING SCHEME 1 Schedule for Submission of Half‐Yearly Returns

For the half‐year ending June : By 31st July For the half‐year ending December : By 31st January

REPORT FOR THE HALF‐YEARLY ENDING.................... Name and Adress of Regional Director of Apprenticeship......................... Training/State/UT/Apprenticeship Adviser.................................................... Telephone No........................ Telex/Fax No....................................... Telegram................................ E‐Mail Address..................................... Sl. No.

Designated Trade

Number of workers other than unskilled workers

Number of apprenticeship seats located by SAA/ RDAT as prescribed ratio

Number of apprentices under Training

Number of apprentices appeared in All India Trade Test held in....... (Month) .......(Year

)

Number of apprentices passed in All India

Trade Test held in..... (Month)

.......(Ysear)

Number of passed out apprentices employed

by the same employer

Fresher ITI passed out

Total

1 2 3 4 5 6 7 8 9 10 Scheduled caste

Scheduled tribe

Other backward classes

Persons with disability Total (14 + 15 +16)

Women Minorities

Visually impaired

Hearing impaired


11 12 13 14 15 16 17 18 19 Date...................... Name and Signature of Apprenticeship Adviser




Date Name and signature of Apprenticeship Advisor Schedule for submission of Half‐Yearly Returns: For the half‐year ending June : By 31st July For the half‐year ending December : By 31st January

REPORT FOR THE HALF‐YEARLY ENDING..........................

Name and Address of Regional Director of Apprenticeship Training........................................................................ Telephone No........................... Telex/Fax No............................. Telegram................................... E‐Mail Address..........................

Sl. No.

State Number of estts. which should be covered under

the Act

Number of establishments where seats have been located

Number of establishments engaging apprentices

Number of apprentice‐ship seats located

Number of apprentices on roll

Up to the end

of previous half‐years

Added/ Deleted during the half years

Total Upto the end

of previous half‐year

Added/ Deleted during the half‐ year

Total

1 2 3 4 5 6 7 8 9 10 11

Out of Apprentices undergoing Training Scheduled Cast

Scheduled Tribe

Other backward Classes

Persons with disability Total Women Minorities

Visually impaired

Hearing Impaired


Date......................... Name and Signature of Regional Director




Schedule for submission of Half‐Yearly Returns:

For the half‐year ending June : By 31st July For the half‐year ending December : By 31st January REPORT FOR THE HALF‐YEARLY ENDING....................... Name and Address of State Apprenticeship Adviser Training........................ Telephone No...................... Telex/Fax No................................................ Telegrams............................. E‐Mail Address.............................................

Sl. No.

Sector Number of estts. which should be covered under the

Act

Number of establishments where seats have been located

Number of establishments engaging apprentices

Number of apprentice‐ship seats located

Number of apprentices

on roll Up to the end



Total Upto the end



Total

1 2 3 4 5 6 7 8 9 10 11 1. State

Public Sector

2. Private Sector

Out of Apprentices undergoing Training

Scheduled Castes

Scheduled Tribes

Other Backward Classes

Persons with Disability Women Minorities

Visually Impaired

Hearing Impaired


Total (15 + 16 + 17)

12 13 14 15 16 17 18 19 20 Date..................... Name and Signature of State/Union Territory Apprenticeship Adviser



FORM APPRENTICESHIP 2 [To be Submitted within Ten Days from the Date of Engagement of Apprentices Applicable only to Graduate or Technician or

Technician (Vocational) Apprentices]

Please state whether the apprentice is a student of Sandwich course: Yes/No

Personal Details

Name and address of establishment

Nature of industry and standard industrial classification Code No.

Registration No. and date of contract of apprenticeship

Subject field in Engineering/ Technology/ Vocational courses

Date of commencement to training

Name and address of apprentice

Name and address of father/guardian

1 2 3 4 5 6 7

Educational qualification at entry

Date, month and year of birth

Examination passed

Name of Institution

Date of passing Emarks

_____________________________________________________________________________ Period of training................................................. Date of completion of Training........................ Rate of Stipend to...............................................

Passport size photo of apprentice



FORM APPENTICESHIP 3 Record of Progress of Apprentice [To be Submitted once in a Quarter in Respect of Graduate or Technician or Technician (Vocational) Apprentices]

1. Name of Apprentice............................................................

2. Registration Number..........................................................

3. Subject field in Engineering or Technology or Vocational Course......................

4. Under training at...........................................................................................................

5. Date of commencement of training............................................................................

6. Area of training during the quarter.............................................................................

7. Progress report for quarter....................................to...................................................

i. Aptitude for training................................................................................................ ii. Performance during the quarter............................................................................ iii. Shortcomings, if any................................................................................................. iv. Reaction of trainee to corrective action at (iii) above....................................... v. Assessment:

Excellent/Above Average/Average/Below Average (Strike out those not applicable)

Signature of Officer/Executive in‐charge of Training

“Remarks.............................................................................. Signature of Manager of the Industry/Establishment.”]

Forms under THE INDUSTRIAL DISPUTES (CENTRAL) RULES, 1957

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ T 1

Forms under

THE INDUSTRIAL DISPUTES (CENTRAL) RULES, 1957



INDEX

FORM A Form of Application for the Reference of an Industrial Dispute to a Board of Conciliation/Court of Enquiry/Labour Court/Tribunal/National Tribunal under Section 10(2) of The Industrial Disputes Act, 1947

FORM B Notice o Parties to Nominate Representatives FORM C Agreement FORM D Summons FORM E Notice of Change of Service Condition Proposed by an Employer FORM F Nomination of Representative FORM G Form of Nomination Paper Form G Progress Report on Constitution and Functioning of Works Committee for the

Half‐Year Ending the 30th June/31st December FORM H Form for Memorandum of Settlement FORM I Complaints under Section 33‐A of The Industrial Disputes Act,1847 FORM J

Application for Permission under Sub Section (1) or Sub –Section (3) of Section 33 of The Industrial Disputes Act, 1947

FORM K

Application under Sub‐Section (2) of Section 33 of The Industrial Disputes Act, 1947

FORM K 1 Application under Sub‐Section (1) of Section 33c of The Industrial Disputes Act, 1947

FORM K 2

Application by a Person Authorised by a Workman or by the Assignee or Heir of a Deceased Workman under Sub‐Section (1) of Section 33‐C of The Industrial Disputes Act, 1947

FORM K 3 Application Under Sub‐Section (2) Of Section 33‐C of The Industrial Disputes Act, 1947

FORM K 4

Application by a Person Who is an Assignee or Heir of a Deceased Workman Under Sub‐Section (2) of Section 33‐C of The Industrial Disputes Act, 1947 (14 of 1947)

FORM L Form of Notice of Strike to be Given by Union/Workmen in Public Utility Service FORM M

Form of Notice of Lock‐Out to be Given by an Employer Carrying on a Public Utility Service

FORM N Form of Report of Strike or Lock‐Out in a Public Utility Service FORM O Register of Settlements



FORM O 1 Notice of Lay off FORM O 2 Notice of End of Lay off FORM O 3

Form of Application for Permission to Lay‐off, to Continue the Lay‐off of Workmen in Industrial Establishments to Which Provisions of Chapter VB of The Industrial Disputes Act, 1947 (14 Of 1947) Apply

FORM P

Form of Notice of Retrenchment to be Given by an Employer Under Clause (C) of Section 25F of Industrial Disputes Act, 1947

FORM PA

Form of Notice for Permission for Retrenchment of Workmen to be Given by an Employer under Clause (D) of Sub‐Section (1) of Section 25N of The Industrial Disputes Act, 1947 (14 Of 1947)

FORM Q

Form of Notice of Closure to be Given by an Employer Under Section 25FFA of The Industrial Disputes Act, 1947 (14 Of 1947)

FORM QA

Form of Notice For Permission of Closure to be Given by an Employer under Sub‐Section (1) of Section 25‐O of The Industrial Disputes Act, 1947 (14 Of 1947)



FORM A

(See rule 3)

Form of Application for the Reference of an Industrial Dispute to a Board of Conciliation/Court of Enquiry/Labour Court/ Tribunal/National Tribunal Under Section 10(2) of The

Industrial Disputes Act, 1947

Whereas an industrial dispute **is apprehended/exists between....................................and..............................and it is expedient that **the matters specified in the enclosed statement which are connected with or relevant to the dispute he should be referred for **enquiry/adjudication by a Board of conciliation/a court of Enquiry/a Labour Court/a Tribunal/a National Tribunal for investigation and settlement, an application is hereby made under sub‐section (2) of section 10 of the Industrial Disputes Act, 1947, that the **said matters/said dispute should be referred to **a Board of conciliation/a Court of Enquiry/a Labour Court/a Tribunal/a National Tribunal. This application is made by the undersigned who have/has been duly authorised to do so by virtue of a resolution (copy enclosed) adopted by a majority of the members present at a meeting of the ...................................held on the................................. 20.... A statement giving the particulars required under rule 3 of the Industrial Disputes(Central) Rules, 1957, is attached. Dated the.................. Signature of employer **..........................................................

or agent............................................................................. or manager....................................................................... or principal officer of the Corporation.....................................................................

Signature of the President of the trade union **..................................... Secretary of the trade union.........................................

Or **Signature of five representatives

duly authorized (vide resolution enclosed)..........................................................................

Or **Signature of the workman...........................

Or **Signature of the workman in the same establishment duly authorised (vide authorisation



enclosed)...................................................................................] To The Secretary to the Government of India, Ministry of Labour. Statement required under rule 3 of the Industrial Disputes (Central) Rules, 1957, to accompany the form of application prescribed under sub‐section (2) of section 10 of the Industrial Disputes Act, 1947:

a. Parties to the dispute including the name and address of the establishment or undertaking involved;

b. Specific matters in dispute; c. Total number of workmen employed in the undertaking affected; d. Estimated number of workmen affected or likely to be affected by the dispute; e. Efforts made by the parties themselves to adjust the dispute.

Copy to—

i. The Assistant Labour Commissioner (Central) .......................................................; [here enter office address of the Assistant Labour Commissioner (Central) in the local area concerned];

ii. The Regional Labour Commissioner (Central); iii. The Chief Labour Commissioner (Central), New Delhi.

**Delete whichever is not applicable.



FORM B (See rule 6)

Notice to Parties to Nominate Representatives

Whereas an industrial dispute has arisen/is apprehended between ........................... and..........................and it is expedient to refer the said dispute under section 10 of the Industrial Disputes Act, 1947, to a Board of Conciliation for the purpose of investigating the same and for promoting a settlement thereof, you are hereby required to intimate to the undersigned not later than the .................... the name(s) and address (es) of one /two person(s) whom you wish to recommend for appointment as your representative(s) on the said Board. If you fail to make the recommendation by the date specified above, the Central Government will select and appoint such person(s) as it thinks fit to represent you.

Secretary to the Government of India, Ministry of Labour.



FORM C (See rule 7)

Agreement [Under section 10A of the Industrial Disputes Act, 1947]

Name of the Parties:

Representing employers: Representing workmen/workman:

It is hereby agreed between the parties to refer the following dispute to the arbitration of ............................................. [here specify the name(s) and address(es) of the arbitrator(s)].

i. Specific matters in disputes; ii. Details of the parties to the dispute including the name and address of the

establishment or undertaking involved; iii. Name of the workman in case he himself is involved in the dispute or the name

of the Union, if any, representing the workmen or workman in question; iv. Total number of workmen employed in the undertaking affected; v. Estimated number of workmen affected or likely to be affected by the dispute.

*We further agree that the majority decisions of the arbitrator(s) be binding on us/ in case the arbitrators are equally divided in their opinion, that they shall appoint another person as umpire whose award shall be binding on us. The arbitrator(s) shall make his (their) award within a period of ....................... (here specify the period agreed upon by the parties) [from the date of publication of tthis agreement in the official Gazzette by the appropriate Government] or within such further time as is extended by mutual agreement between us in writing. In case the award is not made within the period aforementioned, the reference to arbitration shall stand automatically cancelled and we shall be free to negotiate for fresh arbitration.

Signature of the parties Representing employer

**Workman/Representing workman/workmen Witnesses: (1) (2) Copy to:

i. The Assistant Labour Commissioner (Central), (here enter office address of the Conciliation Officer in local area concerned);

ii. The Regional Labour Commissioner (Central)............; iii. The Chief Labour Commissioner (Central), New Delhi; iv. The Secretary to the Government of India, Ministry of Labour, Employment

and Rehabilitation (Department of Labour and Employment), New Delhi.

*Where applicable. **Delete whichever is not applicable.]



FORM D (See rule 17)

Summons

Whereas an industrial dispute between .......................... and ...................................... has been referred to this Board of Conciliation for investigation and settlement, Court of Enquiry for investigation/Labour Court/Tribunal/National Tribunal for adjudication, under section 10 of the Industrial Disputes Act, 1947, you are hereby summoned to appear before the Board/Court/Labour Court/Tribunal/National Tribunal in person on the .............. day of ........... at .......... o’clock in the ............................. noon to answer all material questions relating to the said dispute and you are directed to produce on that day all the books, papers and other documents and things in your possession or under control in any way relating to the matter under investigation by this Board/Court/Labour Court/Tribunal/National Tribunal. Date ............................

Board of Conciliation. Chairman/Secretary,———————————

Court of Enquiry.

Labour Court. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐

Tribunal Presiding Officer/Secretary, —————————————

National Tribunal



FORM E (See rule 34)

Notice of Change of Service Condition Proposed by an Employer

Name of employer.................................................................................................................... Address........................................................................................................................................ Dated the............day of..............20........ In accordance with section 9A of the Industrial Disputes Act, 1947, I/we hereby give notice to all concerned that it is my/our intention to effect the change/changes specified in the annexure, with effect from......................in the conditions of service applicable to workmen in respect of the matters specified in the Fourth Schedule to the said Act.

Signature............................................ Designation.........................................

ANNEXURE (Here specify the change/changes, intended to be effected)

Copy forwarded to:

1. The Secretary of registered trade union, if any; 2. Assistant Labour Commissioner (Central)................................................................................ [here enter office

address of the Assistant Labour Commissioner (Central) in the local area concerned]; 3. Regional Labour Commissioner (Central)............................................................. Zone; 4. Chief Labour Commissioner (Central), New Delhi.


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ T 1 0

FORM F Nomination of Representative

(See rule 36)

Before (Here mention the authority concerned)

Reference No.........................................of....................................................................................................................workmen

Versus ......................................................................................................................................Employer In the matter of …………………………………..I/we hereby authorise Shri/Sarvashree........................ to represent me/us in the above matter. Dated this..............day of............20......

Signature of person(s) nominating the representative(s) Address

Accepted. Signature of representative(s). Address.



FORM G (See rule 47)

Form of Nomination Paper

Name of Industrial Establishment Group/Section/Shop/Department I nominate (here enter the name of the workmen’s representative eligible for election) as a candidate for election to the Works Committee. He is eligible as a voter in the constituency for which he is nominated. Date................................ Signature of proposer. I agree to the proposed nomination.

Signature of candidate. Date...................................... Attested by: (1) (2)

(To be signed by any two voters belonging to the electoral constituency.)



FORM G1 (See rule 56A)

Progress Report on Constitution and Functioning of Works Committee for the Half‐Year Ending the

30th June/*31st December,........................

1. Name and address of the establishment. 2. Name of the employer. 3.

a) Number of workmen employed. b) Name of Unions, if any. c) Affiliation of the Union(s) to the Central Organisations of workers.

4. If the Works Committee has been functioning—

a) Date of its constitution. b) Number of workmen’s representatives (elected members). c) Number of employer’s representatives (nominated members). d) Number of meetings held during the half‐year (with dates).

5. If the Works Committee had not been functioning, the difficulties encountered in its constitution/functioning. 6. General remarks, if any. Date.................................... Signature of employer Place................................... or his representatives. *Strike out the portion not applicable.]



FORM H (See rule 58)

Form for Memorandum of Settlement

Names of Parties: Representing employer(s): Representing workmen:

Short Recital of the Case Terms of settlement

Signature of the parties..........................

...................................... Witnesses:

(1) ................................. (2) .................................

*Signature of Conciliation Officer / Board of Conciliation.

Copy to: ** (1) Assistant Labour Commissioner (Central)............................................. [Here enter the office address of the Assistant Labour Commissioner (Central) in the local area concerned]; (2) Regional Labour Commissioner (Central)........................; (3) Chief Labour Commissioner (Central), New Delhi; (4) The Secretary to the Government of India, Ministry of Labour, New Delhi. *In case of settlements effected by ** In case where settlements are arrived at between the employer and his workmen otherwise than in the course of conciliation proceeding.



FORM I (See rule 59)

Before the Labour Court/ Tribunal / National Tribunal

Complaint under Section 33A of the Industrial Disputes Act, 1947

A............................................ Complainant(s);

Versus

B....................................... Opposite Party(ies). Address: In the matter of : Reference No. ................................... The petitioner(s) begs/beg to complain that the Opposite Party(ies) has/have been guilty of a contravention of the provisions of section 33 of the Industrial Disputes Act, 1947 (14 of 1947), as shown below: (Here set out briefly the particulars showing the manner in which the alleged contravention has taken place and the grounds on which the order or act of the Management is challenged.) The complainant(s) accordingly prays/pray that the Labour Court/ Tribunal/ National Tribunal may be pleased to decide the complaint set out above and pass such order or orders thereon as it may deem fit and proper. The number of copies of the complaint and its annexures required under rule 59 of the Industrial Dispute (Central) Rules, 1957, are submitted herewith.

Signature of the Complainant(s)

Dated this............day of............20..... Verification

I do solemnly declare that what is stated in paragraph.............................. above is true to my knowledge and that what is stated in paragraphs....................................... above is stated upon information received and believed by me to be true. * This verification is signed by me at.................... on ............day of.....................20......

Signature or Thumb impression of the person verifying

* Delete, if not applicable



FORM J [See rule 60 (1)]

Application for Permission under Sub‐Section (1) or Sub‐Section (3) of Section 33

Before (here mention the Conciliation Officer, Board, Labour Court, Tribunal or National Tribunal.) Application for permission under sub‐section (1) / sub‐section (3) of section 33 of the Industrial Disputes Act, 1947 (14 of 1947), in the matter of: Reference No. ................................... Address: A........................... Applicant

Versus

Address(es): B.......................... Opposite Party(ies) The above‐mentioned applicant begs to state as follows:— [Here mention the action specified in clause (a) or clause (b) of sub‐section (1) grounds on which the permission is sought for.] The applicant, therefore, prays that express permission may kindly be granted to him to take the following action namely: [Here mention the action specified in clause (a) or clause (b) of sub‐section (1) / sub‐section (3) of section 33.]

Signature of the applicant.

Dated this.............day of............20....... (Space for Verification)

(Signature of person verifying).

Date (on which the verification was signed) ..................... Place (at which the verification was signed) .................



FORM K [See rule 60(2)]

Application under Sub‐Section (2) of Section 33

Before (here mention the Conciliation Officer, Board, Labour Court, Tribunal or National Tribunal)

Application under sub‐section (2) of section 33 of the Industrial Disputes Act, 1947 (14 of 1947) in the matter of Reference No..........................

A.............................. Applicant. Address:

Versus

B................................Opposite Party(ies).

Address: The above‐mentioned applicant begs to state as follows:—

(Here set out the relevant facts and circumstances of the case.)

* The workmen/workman discharged/dismissed under clause (b) of sub‐section (2) of section 33 has/have been paid wages for one month. The applicant prays that the Conciliation Officer/Board/Labour Court/Tribunal/National Tribunal may be pleased to approve of the action taken namely: [Here mention the action taken under clause (a) or clause (b) of sub‐section (2) of section 33.]

Signature of the applicant.

Space for verification

(Signature of the person verifying).

Dated this.............day of..............20...... Date (on which the verification was signed) ..................... Place (at which the verification was signed) .......... *Delete, if not applicable.



FORM K‐1 [See rule 62(1)]

Application under Sub‐Section (1) of Section 33c of The Industrial Disputes Act, 1947

To 1) The Secretary to the Government of India, Ministry of Labour and Employment, New Delhi. 2) The Regional Labour Commissioner (Central),....................... (here insert the name of the region).

Sir, I/We have to state that I am/we are entitled to receive from M/s...........................a sum of Rs. ............. on account of ................ under the provisions of Chapter VA/Chapter VB of the Industrial Disputes Act, 1947/in terms of the award dated the..................... given by...................../in terms of the settlement dated the .....................arrived at between the said M/s ......................... and their workmen through........................... the duly elected representatives. I/We further state that I/we served the management with a demand notice by registered post on ..................... for the said amount which the management has neither paid nor offered to pay to me/us even though a fortnight has since elapsed. The details of the amount have been mentioned in the statement hereto annexed. I/We request that the said sum may kindly be recovered for the management under sub‐section (1) of section 33C of the Industrial Disputes Act, 1947, and paid to me/us as early as possible. Signature of the applicant(s) Address(es) 1. 2. 3 4.

Station:……………………………………………….. Date: ………………………………………………..

ANNEXURE (Here indicate the details of the amount(s) claimed.)]




Application by a Person Authorised by a Workman or by the Assignee or Heir of a Deceased Workman under Sub‐Section (1)

of Section 33c of the Industrial Disputes Act, 1947 To

1) The Secretary to the Government of India, Ministry of Labour and Employment, New Delhi. 2) The Regional Labour Commissioner (Central).....................................................................................

(here insert the name of the region).

Sir, I *Shri/Shrimati/Kumari...............have to state that *Shri/Shrimati Kumari..................*is/was entitled to receive from M/s....................... a sum of Rs. ................... on account of...................... under the provisions of Chapter VA/Chapter VB of the Industrial Disputes Act, 1947/in terms of the award, dated the..................... given by ...................../in terms of the settlement, dated the.....................arrived at between the said M/s..................... and their workmen through.................. the duly elected representatives. I further state that I served the management with a demand notice by registered post on.....................for the said amount which the management has neither paid nor offered to pay to me even though a fortnight has since elapsed. The details of the amount have been mentioned in the statement hereto annexed. I request that the said sum may kindly be recovered from the management under sub‐section (1) of section 33‐C of the Industrial Disputes Act, 1947, and paid to me as early as possible. *I have been duly authorised in writing by.....................(here insert the name of the workman) to make this application and to receive the payment of the aforesaid amount due to him. *I am the assignee/heir of the deceased workman and am entitled to receive the payment of the aforesaid amount due to him. Station....................... Signature of the applicant..................... Date........................... Address....................................................

ANNEXURE

(Here indicate the details of the amount claimed.) *Strike out the portions inapplicable.]




Application under Sub‐section (2) of Section 33‐C of The Industrial Disputes Act, 1947

Before the Central Government Labour Court at............................ between.........................

1) Name of the applicant(s) 2) Name of the employer

The petitioner(s) ........................... a workman of .........................M/s. .........................of............................ The petitioner(s) undersigned, workmen of ............................ is/are entitled to receive from the said M/s.............................. the money/benefits mentioned in the statement hereto annexed. It is prayed that the court be pleased to determine the amount/amounts due to the petitioner(s). Signature or Thumb‐ Impression(s) of the applicant(s) Address(es) 1. 2. 3. 4. Station.......................... Date.............................

ANNEXURE (Here set out the details of the money due or the benefits accrued together with the case for their admissibility.)]




Application by a Person who is an Assignee or Heir of a Deceased Workman under Sub‐Section (2) of Section 33C

of the Industrial Disputes Act, 1947 (14 of 1947)

Before the Central Government Labour Court at.................................

1. Name of the applicant/applicants 2. Name of the employer

I am/We are the assignee(s) of the deceased workman and am/are entitled to make an application on his behalf. Shri......................., former workman of M/s ............................ of.......................is entitled to receive from the said M/s............................ the money/benefits mentioned in the statement hereto annexed; It is prayed that the court be pleased to determine the amount/amounts due to the deceased workman.

Name and Address of workman...................... Signature or thumb impression of the applicant(s)..................................................

Station....................... Address of the applicant(s).............................. Date...........................

ANNEXURE (Herein set out the details of the money due or the benefits accrued together with the case for their admissibility.)]



FORM L (See rule 71)

Form of Notice of Strike to be given by [Union/Workmen] in Public Utility Service

(Name of Union)

[Names of five elected representatives of workmen.] Dated the......day of......20......

(The name of the employer). Dear Sir/Sirs, In accordance with the provisions contained in sub‐section (1) of section 22 of the Industrial Disputes Act, 1947 —— I/We——————————————— hereby give you notice that ————————————— on.................20....., for the reasons explained in the annexure. Yours faithfully, Secretary of the Union [Five representatives of the workmen duly elected at a meeting held on........................................... (date), vide resolution attached.]

ANNEXURE Statement of the Case. Copy to:

1. Assistant Labour Commissioner (Central)................................................................ (Here enter office address of the Assistant Labour Commissioner (Central) in the local area concerned.)

2. Regional Labour Commissioner (Central).............Zone. 3. Chief Labour Commissioner (Central), New Delhi.

I propose to call a strike

We propose to go on strike



FORM M (See rule 72)

Form of Notice of Lock‐out to be given by an Employer Carrying on a Public Utility Service

Name of employer................................................................................................................... Address..................................................................................................................................... Dated the...............day of................20..... In accordance with the provisions of sub‐section (2) of section 22 of the Industrial Disputes Act, 1947, I/we hereby give notice to all concerned that it is my/our intention to effect a lock‐out, in.......................department(s), section(s) of my/our establishment with effect from.......................for the reasons explained in the annexure.

Signature..................................... Designation................................

ANNEXURE

Statement of Reasons

Copy forwarded to: 1. The Secretary of the Registered Union, if any, 2. Assistant Labour Commissioner (Central).....................................................................

[Here enter office address of the Assistant Labour Commissioner (Central) in the local area concerned.] 3. Regional Labour Commissioner (Central)............Zone. 4. Chief Labour Commissioner (Central), New Delhi.]



FORM N (See rule 73)

Form of Report of Strike or Lock‐out in a Public Utility Service Information to be supplied in this form immediately on the occurrence of a strike or lock‐out in a public utility service to the

Assistant Labour Commissioner (Central) for the local area concerned

Name of Undertaking

Station and District

Normal Working Strength

Number of workers involved

Strike or lockout

Date of commencement of strike or lockout

Cause Was notice of strike or lockout given? If so, on what date for what period?

Is there any permanent agency or agreement in the undertaking for the settlement of disputes between the employer and the workmen? If any exists, particular thereof

Any other information

Directly Indirectly

1 2 3 4 5 6 7 8 9 10 11

Notes.— Column (3) Give the average number of workmen employed during the month previous to the day on which the strike or lock‐out occurred. While reckoning the average, omit the days on which the attendance was not normal for reasons other than individual reasons of particular workmen. Thus days on which strike or lock‐out occurs or communal holiday is enjoyed by a large section of workers should be omitted. Column (4) If, say, 200 workers in a factory strike work and in consequence the whole factory employing 1,000 workers has to be closed than, 200 should be shown under “directly” and the remaining under “indirectly”. If the strike of 200 workers does not affect the working of the other departments of the factory, the number of workers involved would only be 200, which figure should appear under “directly” and column “indirectly” would be blank. Column (8) Give the main causes of the dispute as well as the immediate cause that led to the strike or lock‐out.



FORM O (See rule 75)

Register of Settlements Register ‐ PART I

Serial No. Industry Parties to the

Settlement Date of settlement Remarks*

*Whether the settlement was effected at the intervention of the conciliation machinery, or by mutual negotiations between the parties, may be indicated here.

PART II Should contain one copy each of the settlements in the serial order indicated in Part I.



FORM O‐1 (See rule 75A)

Notice of Lay off To, The Regional Labour Commissioner (Central), ............................................................................ (here specify the region concerned.) Sir, Under rule 75A of the Industrial Disputes (Central) Rules, 1957, I/we hereby inform that I/we have laid of..................................... out of a total of+ ......................workmen employed in the establishment with effect from++....................for the reasons explained in the Annexure. 2. Such of the workmen concerned as are entitled to compensation under section 25C of the Industrial Disputes Act, 1947, will be paid compensation due to them.

Yours faithfully,

** Copy forwarded to Assistant Labour Commissioner (Central)...................................... [Here specify the address of the Assistant Labour Commissioner (Central) of the local area concerned.] +Here insert the number of workmen. ++Here insert the date. **Here insert the position which the person who signs the letter holds with the employer issuing the letter.]

ANNEXURE Statement of Reasons



FORM O‐2 (See rule 75A)

Notice of End of Lay‐off To The Regional Labour Commissioner (Central), ..................................................... (here specify the region concerned.) Sir, As required by rule 75A of the Industrial Disputes (Central) Rules, 1957 and in continuation of my/our notice dated+.......in Form O 1 I/we hereby inform you that the lay‐off in my/our establishment has ended on+................................................

Yours faithfully, ++

Copy to the Assistant Labour Commissioner (Central)................................................... [Here specify the address of the Assistant Labour Commissioner (Central) of the local area concerned]

+Here insert the date. ++Here insert the position with the person who signs the letter holds with the employer issuing the letter.]



FORM O‐3 (To be submitted in triplicate)

[See rule 75B (1)]

Form of Application for Permission to Lay‐off, to Continue the Lay‐off of Workmen in Industrial Establishments to Which Provisions of Chapter VB of The Industrial

Disputes Act, 1947 (14 Of 1947) Apply To ................................. ................................ ................................ [The authority specified under sub‐section (1) of section 25 M] Sir, Under *sub‐section (1)/sub‐section [(3)] of section 25M of the Industrial Disputes Act, 1947 (14 of 1947) read with sub‐rule (1) of rule 75B of the Industrial Disputes (Central) Rules, 1957, I/we hereby apply for *permission to the lay‐off/permission to continue the lay‐off.....................workmen of a total of.......................workmen employed in my/our establishment with effect from....................for the reasons set out in the Annexure. Permission is solicited *for the lay‐off/to continue the lay‐off the said workmen. Such of the workmen permitted to be laid‐off will be paid such compensation, if any, to which they are entitled under sub‐section [(6)] of section 25M, read with section 25C, of the Industrial Disputes Act, 1947 (14 of 1947).

Yours faithfully, (Signature)

*Strike out whatever is inapplicable.



ANNEXURE TO FORM O‐3 (Please give replies against each item)

Item No. 1. Name of the undertaking with complete postal address, including telegraphic address and telephone number. 2. Status of undertaking—

i. Whether Central public sector/State public sector/foreign majority company/ joint sector, etc. ii. If belongs to large industrial house, please indicate the controlling group; and if a foreign majority company,

indicate the extent of foreign holdings. iii. Whether the undertaking is licensed/ registered and if so, name of licensing/ registration authority and

licence/registration certificate numbers. 3.

a. *Names and addresses of the affected workmen proposed to be laid‐off/names and addresses of the workmen laid‐off before the commencement of the Industrial Disputes (Amendment) Act, 1976 (32 of 1976) and the dates from which each of them has been laid‐off.

b. The nature of the duties of the workmen referred to in sub‐item (a), the units/ sections/shops where they are or were working and the wages drawn by them.

4. Items of manufacture and scheduled industry/industries under which they fall. 5. Details relating to installed capacity, licensed capacity and utilised capacity. 6.

i. Annual production, itemwise for preceding three years. ii. Production figures, month‐wise, for the preceding twelve months.

7. Work in progress—item‐wise and value‐wise. 8. Any arrangement regarding off‐loading or sub‐contracting of products or any components thereof. 9. Position of the order book‐item‐wise and value‐wise for a period of six months, and one year next following, and

for the period after the expiry of the said one year.

10. Number of working days in a week with the number of shifts per day and the strength of workmen per each shift.

11. Balance sheets, profit and loss accounts and audit reports for the last three years. 12. Financial position of the company. 13. Names of the inter‐connected companies or companies under the same management. 14.

i. The total number of workmen (categorywise), and the number of employees other than workmen as defined under the Industrial Disputes Act, 1947 (14 of 1947), employed in the undertaking.

ii. Percentage of wages of workmen to the total cost of production. 15. Administrative, general and selling cost in absolute terms per year in the last three years and percentage thereof

to the total cost. 16. Details of lay‐offs resorted to in the last three years (other than the lay‐off for which permission is sought),

including the periods of such lay‐offs, the number of workmen involved in each such lay‐off and the reasons therefor.

17. Anticipated savings due to the *proposed lay off/lay‐off for the continuance of which permission is sought. 18. Any proposal for effecting savings on account of reduction in—

i. managerial remuneration, ii. sales promotion cost, and iii. general administration expenses.



19. Position of stocks on last day of each of the months in the preceding twelve months. 20. Annual sales figures for the last three years and month‐wise sales figures for the preceding twelve months both

item‐wise and value‐wise. 21. Reasons for the *proposed lay‐off/lay‐off for the continuance of which permission is sought. 22. Any specific attempts made so far to avoid the *proposed lay‐off/lay‐off for the continuance of which permission

is sought. 23. Any other relevant factors with details thereof. *Strike out whatever is inapplicable.]



FORM P (See rule 76)

Form of Notice of Retrenchment to be given by an Employer under Clause (C) of Section 25f of

Industrial Disputes Act, 1947 Name of employer............................... Address.................................................... Dated .............. day of..............20........ To, The Secretary to the Government of India, Ministry of Labour, New Delhi Sir, Under clause (c) of section 25F of the Industrial Disputes Act, 1947 (14 of 1947), I/we hereby inform you that I/we have decided to retrench*...................... workmen with effect from**........................ for the reasons explained in the Annexure. 2. +The workmen concerned were given on the.**........ 20......one month’s notice in writing as required under clause (a) of section 25F of the Act. Retrenchment is being effected in pursuance of an agreement, a copy of which is enclosed. The workmen were given on the ** ................... 20 ...... one monthʹs pay in lieu of notice as required under clause (a) of section 25‐F of that Act. 3. The total number of workmen employed in the industrial establishment is*** ......... and the total number of those who will be affected by the retrenchment is given below: Category and designation of workmen to be retrenched

Number of workmen Employed To be retrenched

1 2 3 4. I/We hereby declare that the workman/workmen concerned has/have been/will be paid compensation due to them under section 25F of the Act on **........................./the expiry of the notice period.

Yours faithfully,

++ *Here insert the number of workmen. **Here insert the date. +Delete the portion which is not applicable. ***Here insert the total number of workmen employed in the industrial establishment. ++Here insert the position which the person who signs this letter holds with the employer issuing the letter.

ANNEXURE Statement of Reasons

Copy to : 1. Assistant Labour Commissioner (Central). ............................................................

[Here enter office address of the Assistant Labour Commissioner (Central) in local area concerned.] 2. Regional Labour Commissioner (Central)……………………………….Zone 3. Employment Officer, Employment Exchange........................................................... (Enter the full address of the

Employment Exchange concerned.)]



FORM P‐A (To be made in triplicate)

[See rule 76A(1)]

Form of Notice for Permission for Retrenchment of Workmen to be given by an Employer under

Clause 4[(d)] of Sub‐Section (1) of Section 25‐N of The Industrial Disputes Act, 1947 (14 of 1947)

Date...................... To .................................... ................................... .................................... [The Central Government/authority* specified under clause (c) of sub‐section (1) of section 25N]. Sir, 1. Under clause (c) of sub‐section (1) of section 25N of the Industrial Disputes Act, 1947 (14 of 1947), I/we hereby

inform you that *I/we propose to retrench.......................workmen [being workmen to whom sub‐section (1) of section 25N applies] with effect from......................for the reasons set out in the Annexure.

2. The workmen *concerned have been given notice in writing as required under clause (a) of sub‐section (1) of

section 25N/have not been given notice since the retrenchment is under an agreement (copy of which is enclosed) as provided in the proviso to the said clause.

3. The total number of workmen employed in the industrial establishment is..................................and the total

number of those who will be affected by the proposed retrenchment is as given below: Category and designation of workmen to be retrenched

Number of workmen Employed To be retrenched

(1) (2) (3)

4. Permission is solicited for the proposed retrenchment under clause (c) of subsection (1) of section 25N.

compensation due to them under clause (b) of sub‐section (1) of section 25N of the Act. 5. I/We hereby declare that the workmen permitted to be retrenched will be paid compensation due to them under

clause (b) of Sub‐Section (1) of Section 25‐N of the Act.

Yours faithfully, (Signature)

*Strike out whatever is inapplicable.]



ANNEXURE TO FPRM P‐A (Please give replies against each item)

Item No. 1. Name of the undertaking with complete postal address, including telegraphic addresses and telephone number. 2. Status of undertaking—

i. Whether Central public sector/State public sector / foreign majority company/joint sector, etc. ii. If belongs to large industrial house, please indicate the controlling group; and if a foreign majority company,

indicate the extent of foreign holdings. iii. Whether the undertaking is licensed/ registered and if so, name of licensing/registration authority and

licence registration certificate numbers. 3. Names and addresses of the workmen proposed to be retrenched and the nature of the duties, the

units/sections/shops where they are working and the wages drawn by them. 4. Items of manufacture and scheduled industry/industries under which they fall. 5. Details relating to installed capacity licensed capacity and the utilised capacity. 6.

i. Annual production, item‐wise for preceding three years. ii. Production figures month‐wise for preceding twelve months.

7. Work in progress—item‐wise and valuewise. 8. Any arrangement regarding off‐loading or sub‐contracting of products or any components thereof. 9. Position of the order book—item‐wise and value‐wise for a period of six months and one year next following,

and for the period after the expiry of the said one year. 10. Number of working days in a week with number of shifts per day and strength of workmen per each shift. 11. Balance sheet; profit and loss account and audit reports for the last three years. 12. Financial position of the company. 13. Names of the inter‐connected companies or companies under the same management. 14.

i. The total number of workmen (category‐wise), and the number of employees other than workmen as defined in the Industrial Disputes Act, 1947 (14 of 1947), employed in the undertaking.

ii. Percentage of wages of workmen to the total cost of production. 15. Administrative, general and selling cost in absolute terms per year for the last three years and percentage thereof

to the total costs. 16. Details of retrenchment resorted to in the last three years, including dates of retrenchment, the number of

workmen involved in each case, and the reasons therefor. 17. Has any of the retrenched workmen been given re‐employment and if so, when? Give details. 18. Are seniority lists maintained in respect of the categories of workmen proposed to be retrenched and if so, the

details and the position of the workmen affected indicating their length of service including broken periods of service?

19. Anticipated savings due to the proposed retrenchment. 20. Any proposal for effecting savings on account of reduction in—

i. managerial remuneration, ii. sales promotion cost, and iii. general administration expenses.

21. Position of stocks on the last day of each of the month in the preceding twelve months. 22. Annual sales figures for the last three years and month‐wise sales figures—for the preceding twelve months both

item‐wise and value‐wise. 23. Reasons for the proposed retrenchment. 24. Any specific attempt made so far to avoid the proposed retrenchment. 25. Any other relevant factors with details thereof.



FORM Q (See rule 76A)

Form of Notice of Closure to be given by an Employer Under Section 25ffa of the Industrial Disputes

Act, 1947 (14 of 1947)

Name of employer......................................... Address........................................................ Dated the....... day of......20..... To

The Secretary to the Government of India, Department of Labour and Employment, New Delhi.

Sir, Under section 25FFA of the Industrial Disputes Act, 1947 (14 of 1947), I/we* hereby inform you that I/we have decided to close down.........................(name of the undertaking) with effect from.....................for the reasons explained in the annexure. The number of workmen whose services would be terminated on account of the closure of the undertaking is................. (number of workmen).

Yours faithfully,

*(Here insert the position which the person who signs this letter holds with the employer issuing this letter.)

ANNEXURE Statement of reasons

Copy to:

1) The Regional Labour Commissioner (Central)*......................................................... 2) The Assistant Labour Commissioner (Central)*........................................................ 3) The Employment Exchange*.........................................................................................

*(Here enter the office address of the Regional Labour Commissioner (Central)/ Assistant Labour Commissioner (Central) and the Employment Exchange in the local area concerned).]



FORM QA (To be submitted in triplicate)

[See rule 76C(1)]

Form of Notice for Permission of Closure to be given by an Employer under Sub‐Section (1) of Section 25‐O of

The Industrial Disputes Act, 1947 (14 of 1947) Date......................

To, The Secretary to the Government of India, Ministry of Labour, New Delhi. Sir, 1. Under section 25C of the Industrial Disputes Act, 1947 (14 of 1947), I/we hereby inform you that I/we propose to

close down the undertaking specified below of (name of the industrial establishment). (Give details of the undertaking) .................................................................................................................................................... with effect from......................for the reasons explained in the Annexure. 2. The number of workmen whose services will be terminated on account of the closure of the undertaking

is.................(number of workmen). 3. Permission is solicited for the proposed closure.

4. I/we hereby declare that in the event of approval for the closure being granted, every workman in the undertaking to whom sub‐section (8) of the said section 25‐O applies shall be paid compensation as specified in that section.

Yours faithfully,

(Signature)



ANNEXURE TO FORM QA (Please give replies against each item)

Item No. 1. Name of the industrial establishment with complete postal address, including telegraphic addresses and

telephone number. 2. Status of undertaking:—

i. Whether Central public sector/State public sector/foreign majority company/ joint sector, etc. ii. If belongs to large industrial house, please indicate the controlling group; and if a foreign majority company,

indicate the extent of foreign holdings. iii. Whether the undertaking is licensed/ registered and if so, name of licensing/ registration authority and

licence/registration certificate numbers. 3. The total number and categories of workmen affected by the proposed closure, along with the addresses of the

workmen and the details of wages drawn by them. 4. Items of manufacture and scheduled industry/industries under which they fall. 5. Details relating to licensed capacity, installed capacity and the utilised capacity. 6.

i. Annual production item‐wise for preceding three years. ii. Production figures month‐wise for the preceding twelve months.

7. Work in progress—item‐wise and value‐wise. 8. Any arrangement regarding off‐loading or sub‐contracting of products or any component thereof. 9. Details of persons or the organisation to whom the job/jobs is/are being entrusted‐relationship/interest of the

persons/organisations with the director/directors or the officer/officers of the company. 10. Position of the order book—item‐wise and value‐wise for a period of six months and one year next following,

and for the period after the expiry of the said one year. 11. Number of working days in week with the number of shifts per day and the strength of workmen per each shift. 12. Balance‐sheet and profit and loss account and audit reports for the last three years. 13. Financial position of the company. 14.

i. Names of inter‐connected company or companies under the same management. ii. Details about intercorporate investment and changes during the last one year. iii. Interest of any of the directors/officers of the undertaking producing same or similar type of product.

15. Percentage of wages of workmen to the total cost of production. 16. Administrative, general and selling cost in absolute terms per year for the last three years and percentage thereof

to the total cost. 17. Inventory position—item‐wise and value‐wise for the preceding twelve months (Inventories to be shown in

respect of finished products, components and raw materials to be shown separately item‐wise and value‐wise). 18. Selling arrangement for the last three years and any change in the selling arrangement in preceding twelve

months. 19. Full details of the interests of the directors and officers of the company in the organisations/persons involved in

selling products of the undertaking. 20. Buying arrangements for raw materials and components. 21. Interests of the directors and officers with the organisations/persons involved in buying raw materials and

components for the undertaking. 22. Annual sales figures for the three years and month‐wise sales figures for the preceding twelve months both item‐

wise and value‐wise. 23. Reasons for the proposed closure. 24. Any specific attempts made so far to avoid the closure. 25. Any other relevant factors with details thereof.]

Forms under CENTRAL TRADE UNION REGULATIONS, 1938

C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ U 1

Forms under

CENTRAL TRADE UNION REGULATIONS, 1938



INDEX

FORM A Application for Registration of Trade Union

FORM B Register of Trade Unions

FORM C

Certificate of Registration of Trade Union

FORM D

Annual Return Prescribed under Section 28 of The Indian Trade Unions Act, 1926,



FORM A

Application for Registration of Trade Union Date the............... day of............... 20.....

1. We hereby apply for the registration of a Trade Union under the name of........

2. The address of the head office of the Union is..............

3. The Union came into existence on the...............day of............... 20....

4. The Union is a Union of employers/workers engaged in the industry (or profession). 5. The particulars required by section 5(1)(c) of the Indian Trade Unions Act, 1926, are given in Schedule I. 6. The particulars given in Schedule II show the provisions made in the rules for the matters detailed in section

6 of the Indian Trade Unions Act, 1926. 7. (To be struck out in the case of unions which have not been in existence for one year before the date of

application). The particulars required by section 5(2) of the Indian Trade Unions Act, 1926, are given in Schedule* III.

8. We have been duly authorized to make this application. Signature Occupation Address

Signed 1

2

3

4

5

6

7

To the Registrar of Central Trade Unions, Delhi. *State here whether the authority was given by a resolution of a general meeting of the Union, if not, in what other way it was given.

SCHEDULE I—LIST OF OFFICERS

Title Name Age Address Occupation

Note: Enter in this Schedule the names of all members of the executive of the Union showing in column 1 the names of any posts held by them (e.g., President, Secretary, Treasurer, etc.) in addition to their offices as members of the executive.



SCHEDULE II—REFERENCE TO RULES

The numbers of the rules‐making provision for the several matters detailed in column 1 are given in column 2 below:

Matter Number of rules Name of union

The whole of the objects for which the union has been established.

The whole of the purposes for which the general funds of the union shall be applicable.

The maintenance of a list of members.

The facilities provided for the inspection of the list of members by officers and members.

The admission of ordinary members.

The admission of honorary or temporary members.

The conditions under which members are entitled to benefit assured by the rules.

The conditions under which fines or forfeitures can be imposed or varied.

The manner in which the rule shall be amended, varied or rescinded.

The manner in which the members of the executive and the other officers of the union shall be appointed and removed.

The safe custody of the funds.

The annual audit of the accounts.

The facilities for the inspection of the account books by officers and members.

The manner in which the union may be dissolved.



SCHEDULE II

Statement of Liabilities and Assets on the ........Day of.......20.......

(This need not be filled in if the Union came into existence less than one year before the date of application for registration.)

Liabilities Rs. P. Assets Rs. P

Amounts of General Fund Amounts of political fund Loans ……….. from Other liabilities (to be specified)

Cash – In hands of treasurer In the hands of Secretary In the hands of –

In the bank In the bank

Securities as per list below Unpaid subscriptions due Loans to Immovable property Goods and furniture Other assets (to be specified)

Total Liabilities Total Assets

List of Securities

Particulars Nominal Market Value In hands of 1…. 2…. 3…. 4….

5…6…. 7…



FORM B Register of Trade Unions

Serial No. Officers Name of Union

Address of Head Office

Date of Registration

Year of entering in office

Nam

e

Age of entry

Add

ress

Occup

ation

Year of relinqu

ishing

offic

e

Other offices held in

additio

n to m

embership

of executiv

e with date

Number of applications from List of members applying for registration

1. 2. 3. 4. 5. 6.



FORM C Certificate of Registration of Trade Union

No.

It is hereby certified that the ............................. has been registered under the Indian Trade Unions Act, 1926, this............day of.............20.....

Seal

Registrar of Central Trade Unions



FORM D

Annual Return Prescribed under Section 28 of The Indian Trade Unions Act, 1926, for The Year Ending on 31st March, 20.......

Name of Union. Registered Head Office. Number of certificate of registration.

Return to be made by federations of Trade Union This return need not be made by federations of Trade Unions.

Number of unions affiliated at the beginning of year.

Number of unions joining during the year.

Number of unions disaffiliated at the end of year.

Number of members on books at the beginning of year.

Number of members admitted during the year (add) together.

Number of members who left during the year (deduct).

Total number of members on books at the end of the year.

Males

Females

Number of members contributing to political fund.

A copy of the rules of the Trade Union, corrected up to the date of dispatch of this return, is appended. Dated the..................... Secretary Statement of liabilities and assets on the ..............day of ............20..... Liabilities Rs. P. Assets Rs. P. Amount of general fund Amount of political fund Loans .... from Debts due to Other liabilities (to be specified)

Cash— In hands of Treasurer In hands of Secretary In hands of—

In the Bank In the Bank

Securities as per list below Unpaid subscriptions due Loans to— Immovable property Goods and furniture Other assets (to be specified)

Total Liabilities

Total Assets



List of securities Particulars Nominal Value Market Value at date on

which accounts have been made up

In hands of

Treasurer

General Fund Account Income Rs. P. Expenditure

Rs. P.

Balance at beginning of year

Contributions from members as per member

Donations

Sale of periodicals, rules,

etc.

Interest on investments

Income from miscellaneous

sources (to be specified)

Salaries, allowances and expenses of officers

Salaries, allowances and expenses of establishment ..

Auditor’s fee ..

Legal expenses ..

Expenses in conducting trade disputes

Compensation paid to members for loss arising out of trade disputes

Funeral, old age, sickness, unemployment benefits, etc.

Educational, social and religious benefits

Cost of publishing periodical ..

Rents, rates and taxes ..

Stationery, printing and postage ..

Expenses incurred under section

15(j) of the Indian Trade Unions

Act, 1926 (to be specified)

Other expenses (to be specified)

Balance at the end of year ..

Total Total


C o m p i l e d b y P o w e r H R F o r u m P a g e ‐ U 1 0

Political Fund Account Income Rs. P. Expenditure

Rs. P.

Balance at beginning of year

Contribution from members as per member..

Total

Payments made on objects specified in section 16(2) of the Indian Trade Unions Act, 1926 (to be specified) ..

Expenses of managements (to be specified).

Balance at the end of year

Total

Auditor’s Declaration

The undersigned, having had access to all the books and accounts to the Trade Union and having examined the foregoing Statements and verified the same as found to be correct, duly vouched and in accordance with the law, subject to the remarks, if any, appended hereto.

Auditor.

The following changes of officers have been made during the year—

Officers Relinquishing Office Name Office Date of Relinquishing

Officers Appointed

Name Age Office Address Occupation Date of

appointment

Secretary

INDEX OF FORMS FOR REGISTRATION, CERTIFICATION & LICENSE

C o m p i l e d b y P o w e r H R F o r u m P a g e V 1




1. The Industrial Employment (Standing Orders) Central Rules, 1946

FORM I Submission of draft Standing orders

FORM II Certification of standing orders

2. Building and Other Construction Workers’ (Regulation of Employment and Conditions of Service) Central Rules, 1998

FORM I Application for Registration of Establishments Employing Building Workers


FORM V

Certificate of initial and periodical test and examination of winches, derricks and their accessory gear

FORM VI

Certificate of initial and periodical test and examination of

cranes or hoists and their accessory gear

FORM VII Certificate of initial and periodical test and examination of loose gears

FORM VIII Certificate of test and examination of wirerope before being taken into use

FORM IX Certificate of annealing of loose gears

FORM X Certificate of annual thorough examination of loose gears exempted from annealing

FORM XI Certificate of Medical Examination



3. Contract Labor (Regulation and Abolition) Central Rules, 1971

FORM I Application for Registration of Establishments Employing Contract Labour


FORM IV Application for Licence

FORM V Form of Certificate by Principal Employer

FORM VI License

FORM VII Application for Renewal of License

FORM VIII

Application for Temporary Registration of Establishment

Employing Contract Labour

FORM IX Temporary Certificate of Registration

FORM X Application for Temporary License

FORM XI License for a period of not more than fifteen days

4. Inter‐State Migrant Workmen (Regulation of Employment and Condition of Service) Central Rules, 1980

FORM I Application for registration of establishments employing migrant workmen

FORM II Certificate of registration

FORM IV Application for licence for recruitment

FORM V Application for licence for employment

FORM VI Form of certificate by principal employer

FORM VII Form of certificate by principal employer

FORM IX Application for renewal of licence



5. Dangerous Machines (Regulation) Rules, 2007

FORM I

Form of licence for manufacture or commencement of carrying on business as a manufacturer of a dangerous machine

FORM II

Form of licence for commencement or carrying on business as a dealer of a dangerous machine

6. Environment (Protection) Rules, 1986

FORM I

Notice of intention to have sample analyzed

7. Delhi Factory Rules, 1950

FORM 1

Application for permission to construct, extend or take into use any building as a factory

FORM 2 Application for registration and grant or renewal of license for the year and notice of occupation specified in sections 6 & 7

FORM 4 License to work a factor

8. The Delhi Shops and Establishment Rules, 1954

FORM A Statement under Section 5 (1)

FORM C Registration Certificate of establishment

FORM L Renewal of Registration Certificate



9. The Employees’ Provident Funds Scheme, 1952

FORM 1 Exemption under paragraph 27 of the scheme

10. The Employees’ State Insurance (General) Regulations, 1950

FORM 01 Employer’s registration form

11. The Apprenticeship Rules, 1992

FORMAT 1A

Intimation regarding engagement of apprentices and forwarding their contracts for registration

12. The Industrial Disputes (Central)Rules,1957

FORM O 3

Form of application for permission to lay‐off, to continue the lay‐off of workmen in industrial establishments to which provisions of Chapter VB of the Industrial disputes act, 1947 (14 of 1947) apply

FORM PA

Form of notice for permission for retrenchment of workmen to be given by an employer under Clause (d) of Sub‐Section (1) of section 25N of The Industrial Disputes Act, 1947 (14 of 1947)

FORM QA

Form of notice for permission of closure to be given by an employer under Sub‐Section (1) of Section 25‐O of The Industrial Disputes Act, 1947 (14 of 1947)

INDEX OF FORMS FOR MAINTAINING RESGISTERS AND RECORDS

C o m p i l e d b y P o w e r H R F o r u m P a g e W 1

INDEX OF FORMS FOR MAINTAINING REGISTERS AND RECORDS



1. The Industrial Employment (Standing Orders) Central Rules, 1946

Form III Register under Section 8

2. Building and Other Construction Workers’ (Regulation of Employment and Conditions of Service) Central Rules, 1998


FORM XII Health Register

FORM XV Register of Building Workers Employed by the Employer

FORM XVI Muster‐Roll


FORM XVIII Form of Register of Wages‐Cum‐Muster‐Roll

FORM XIX Register of deductions for damage or loss

FORM XX Register of fines

FORM XXI Register of Advances

FORM XXII Register of Overtime

FORM XXVI

Register of Periodical Test—Examination of Lifting

Appliance and Gears etc






FORM XIII Register of Workmen Employed by Contractor

FORM XVI Muster roll


FORM XVIII Form of Register of Wages‐cum‐Muster Roll

FORM XX Register of Deductions for Damage or Loss

FORM XXI Register of Fines

FORM XXII Register of Advances

FORM XXIII Register of Overtime

4. Inter‐State Migrant Workmen (Regulation of Employment and Condition of Service) Central Rules, 1980 FORM III Register of establishments


FORM XIII Register of workmen employed by contractor

FORM XVII Muster roll

FORM XVIII Register of wages

FORM XIX Register of deduction for damage or loss

FORM XX Register of fines

FORM XXI Register of advances

FORM XXII Register of overtime



5. Mines Rules, 1955 FORM ‐B Register of employees ( See Rules 48(3), 51, 77 and 77.A(2)))

FORM ‐C Register of persons employed below ground during the weak

FORM ‐D Register of persons employed above ground in opencast working during the week

FORM ‐E Register of persons employed above ground otherwise than in opencast working during the week

FORM‐F Register of compensatory days of rest

FORM‐G Register of leave account during the calendar year

FORM‐H Register of leave wages account during the calendar year

FORM ‐I Register of overtime wages

6. Delhi Factory Rules, 1950 FORM 6 Humidity register under rule 22

FORM. 7 Record of lime washing, painting etc. Under rule 16

FORM 9 Register of compensatory holidays under rule 77

FORM 10 Overtime muster roll of exempted workers under rule 78

FORM 12 Register of adult workers under rule 80

FORM 15 Register of leave with wages under rule 87 & 88

FORM 16 Leave book under rule 87 & 88

FORM 17 Health register under rule 14

FORM 26 Muster roll under rule 103

FORM 27 Register of accidents and dangerous occurrences under rule 104



7. The Delhi Shops and Establishment Rules, 1954 FORM B Register of Establishments





FORM 6 Register of employees

FORM 11 Accident book

9. The Workmen’s Compensation Rules, 1924

FORM C Statement of disbursements

FORM R Register of agreements

10. The Minimum Wages (Central) Rules, 1950

FORM I Register of fines

FORM II Register of deductions for damage or loss caused to the employer, by the neglect or default of the employed persons

FORM IV Overtime register for workers

FORM V Muster roll

FORM X Register of wages



11. The Payment of Bonus Rules, 1975

FORM C Bonus Paid to Employees for the Accounting Year

12. Equal Remuneration Rules, 1976

FORM D Register to be maintained by the employer under Rule (6) of the Equal Remuneration Rules, 1976


FORMAT 2

Proforma of work diary


FORM O Register of settlements

15. The Central Trade Union Regulations, 1938 FORM B Register of trade unions

INDEX OF FORMS FOR FILLING RETURNS

C o m p i l e d b y P o w e r H R F o r u m P a g e X 1




1. Building and other Construction Workers’ (Regulation of Employment and Conditions of Service) Central Rules, 1998

FORM XXV Annual Return of Employer to be sent to the Registering Officer


FORM XXIV Return to be sent by the Contractor to the Licensing Officer

FORM XXV Annual Return of Principal Employer to be sent to the Registering Officer

3. Inter‐State Migrant Workmen (Regulation of Employment and Condition of Service) Central Rules, 1980

FORM XI Return to be sent by the contractor to the authorities specified under Explanation below sub‐section (2) of section 12

FORM XXIII Return to be sent by the contractor to the licensing officer

FORM XXIV

Annual return of principal employer to be sent to the Registering officer

4. Mines Rules, 1955 FORM ‐K Return of minor accidents

FORM ‐T Annual Return for the year ending on the 31st December



5. Environment (Protection) Rules, 1986

FORM V Environmental statement for the financial year 6. Delhi Factory Rules, 1950

FORM 21 (NOW FORM NO.34)

Annual return under rule 100

FORM 22 Half‐ yearly return under rule 100

FORM.24 Annual return (creche) under rule 100

7. The Employees’ Provident Funds Scheme, 1952

FORM 5

Return of employees qualifying for membership of the employeesʹ provident fund, employeesʹ pension fund

And employeesʹ deposit linked insurance fund for the first time

FORM 5A Return of ownership to be sent to the regional commissioner

FORM 6 (Revised)

Return of the contribution cards sent to the

Commissioner on the expiry of the period of currency

FORM 6A

Consolidated annual contribution statement (For unexempted establishments only)

FORM 12 (Revised)

Statement of monthly contributions

FORM 12A (Revised)

Statement of monthly contributions (For Unexempted Establishments only)




FORM 01(A) Form of Annual Information of Factory/Establishment covered under ESI

Act

FORM 5 Return of contributions

FORM 5A Statement of advance contributions made for the contribution period

9. The Workmen’s Compensation Rules, 1924

FORM EE Report of fatal accidents

10. The Minimum Wages (Central) Rules, 1950

FORM III Annual returns

11. Payment of Bonus Rules,1975

FORM D

Annual Return—Bonus Paid to Employees for The Accounting Year

12. Employment Exchange (Compulsory Notification Of Vacancies) Rules, 1960

FORM ER‐I Quarterly return to be submitted to the local Employment Exchange

FORM ER‐II

Occupational return to be submitted to the Local Employment Exchanges once in two years




FORMAT 1A Intimation regarding engagement of apprentices and forwarding their contracts for registration

FORM APPRENTICESHIP 1 Submission of Half Yearly Returns

APPRENTICESHIP TRAINING SCHEME 1



Submission of Half‐Yearly Returns:


submission of Half‐Yearly Returns


To be submitted within ten days from the date of engagement of apprentices applicable only to graduate or technician or technician (vocational) apprentices

FORM APPENTICESHIP 3

Record of progress of apprentice to be submitted once in a quarter in respect of graduate or technician or technician (vocational) apprentices


FORM G Progress report on constitution and functioning of works committee for the half‐year ending the 30th June/31st December

FORM N Form of report of strike or lock‐out in a public utility service