FORM A-1
(Rule 3 –
A)
Statement of employees' and employer's contribution as on 30th June and 31st December respectively.
1. Name & Address of the establishment
2. Name of the Employer
___________________________
3. Class of establishment ____________________________________
(
i.e. whether a factory or motor omnibus
service, a Shop, Commercial establishment, Residential
Hotel, Restaurant, Eating-house,Theatre or other places of public amusement or entertainment )
SLAB:I SLAB:II
Employees drawing wages/salary Employees drawing wages/salary
upto & inclusive of Rs.3000/-p.m. exceeding Rs.3000/-p.m.
EMPLOYEES’ CONTRIBUTION Rs. 6.00 EMPLOYEES’ CONTRIBUTION Rs. 12.00
EMPLOYER’S CONTRIBUTION Rs.18.00 EMPLOYER’S CONTRIBUTION Rs. 36.00
i.e. Rs.48/- per person
No.of
Employees
Employees’
Contribution
Rs.
Employer’s
Contribution
Rs.
Penal
Interest
Rs.
Total
Rs.
(A) Establishment -
Slab: I
Employees -
Slab: II
(B) Contract
-
Slab: I
Employees -
Slab: II
Total of sub-entries (a) and (b) of entry 4
5. Whether the contribution has already been
paid to the Welfare Commissioner: if so
whether by cheque, or cash and details therof
6. Mode of Payment : Cash / Cheque / D.D. No.______________
Date_____________Amt.______________
Name of the Bank : _____________________________
Branch : ______________________________________
Signature of the employer
ESTABLISHMENT CODE NO.
4.
Total number of employees whose names
stand on the establishment register as on
30
th
June / 31
st
December
Instructions overleaf
MAHARASHTRA LABOUR WELFARE BOARD
(AN ISO 9001-2008 CERTIFIED)
Hutatma Babu Genu Mumbai Girni Kamgar Krida Bhavan,
Senapati Bapat Marg , Elphinstone ( W ) Mumbai - 400 013
Tel : 43226809 / 43226830 / 433226807 / 43226818 Fax : 43226822
E-mail : [email protected]
..2..
Instruction regarding Payment:
1. Cheque/D.D. Should be drawn in favour of Maharashtra Labour Welfare Fund.
2. Cheque/D.D. Should be payable at MUMBAI only.
3. Cheque/D.D. Should be issued separately for each Establishment.
4. Both the Employees’ & Employer’s Contribution should be paid only by single cheque.
5. Cash Payment will be accepted from 10.30 a.m. to 3.00 p.m. (Lunch hour 1.00 to 1.30 p.m.)
6. Estt. Code Number allotted to you should be quoted at proper place provided in this form.
7. Please write the Estt. Code Number on the backside of the Cheque/D.D.
8. Name of the person for communication & Telephone No.,Fax No. Email address.
9. Use xerox copy of this form for Every Payments.
