Form 5A(Revised) | Mangalore EPFO

FORM NO-5-A (REVISED)
(For unexempted Establishments only)
The Employees’ provident Fund Scheme, 1952 (Para 36-A)
The Employees’ Family Pension Scheme, 1971 (Para 16)
The Employees’ Deposit Linked Insurance Scheme, 1976 (Para-1)
The Employees’ Pension Scheme, 1995
RETURN OF OWNERSHIP TO BE SENT TO THE REGIONAL COMMISSIONER

1. Name of the establishment
2. Code No. of the establishment under the 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 owner or leases (if by leases period of the lease should be indicated)
8. Particulars of owners.
Name
Father’s Name
Status
Age
Date from Which in position
Residential Address
1
2
3
4
5
6
1.
2.
3.
4.
5.
*whether proprietor, Partner, MG, Partner, MG, Director etc…
9. If on Lease, Particulars of leases
Name
Father’s Name
Age
Residential Address
Date from Which in position
1
2
3
4
5
1.
2.
3.
4.
5.
10. If registered under the factories Act particulars of Manager/Occupier
Name
Father’s Name
Age
Residential Address
Date from Which in position
1
2
3
4
5
A.
B.
11. Particular of The Persons mentioned above, who are in change of and responsible for the conduct of the business of the establishment.
Name
Father’s Name
Age
Residential Address
1
2
3
4
1
2
3
4
5
Dated:
Signature of the Employer/Designation seal of the Establishment
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.