Challan

EMPLOYEES STATE INSURANCE CORPORATION
ORIGINAL
For Bank
Challan Form for Deposit in A/c No. 1

Employers Code 5175787101
Region code
5
Employer code
7
Industry
Code
7
Date
Month
Year
Bank & Branch Code*
Name of
Factory /
Estt. &
Address
M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,

2A&B, III FLOOR, RAJA ANNAMALAI BUILDING,
NO.19,MARSHALLS ROAD, CHENNAI - 08.
Mode of Payment [Tick ()]

Cash
Cheque/D.D.No.
Dated:
Drawn on (Name of the Bank/Branch)
TAMILNAD MERCANTILE BANK LTD TTK ROAD, CHENNAI.
Cheque
D.D.
Period of contribution
Month - SEPTEMBER
Regular Contribution
Nature of Payment [Tick ()]

Total Wages : Rs.
Year - 2011
Interest
Others
Damages
No. of Employees: 7
Rs.
Ps.
Employees Contribution
1 2 2 5
0 0
Employers contribution
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
Total amount (in words) (Four Thousand Five Hundred and Seventy Seven Only)
____________________________________________________________________________________
R.O. Demand Letter No. & Date __________________________________________________________
Bank
Seal
______________________________________
Signature
______________________________________
Name & Designation Seal of Authorised Signatory
____________________________________________________________________________________
Acknowledgement (to be filled by Depositor)
____________________________________________________________________________________
Received Rs.4577.00
(Rs. Four Thousand Five Hundred and Seventy Seven only)
In Cash /by Cheque/DD No. .. Dated.. Subject to
Realisation) Drawn on .... (Bank) in favour of ESIC A/c No.1
* (For Bank Branch Code see on reverse)
For use in Bank

Bank Scroll No. .
Date: .
Authorised signature & Seal of the Receiving
Bank
Important: Affix Correct Code No. Name Seal

and Period of contribution to avoid missing credit
DUPLICATE
For ESIC through Bank

Region code
5
Employer code
7
Industry
Code
7
Date
Month
Year
Bank & Branch Code*
Name of
Factory /
Estt. &
Address


Cash
Cheque/D.D.No.
Dated:
Cheque
D.D.
Month - SEPTEMBER

Total Wages : Rs.
Year - 2011
Interest
Others
Damages
No. of Employees: 7
Rs.
Ps.
1 2 2 5
0 0
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
____________________________________________________________________________________
Bank
Seal
______________________________________
Signature
______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Received Rs.4577.00
For use in Bank

Bank Scroll No. .
Date: .
Bank

TRIPLICATE
For Depositor

Region code
5
Employer code
7
Industry
Code
7
Date
Month
Year
Bank & Branch Code*
Name of
Factory /
Estt. &
Address


Cash
Cheque/D.D.No.
Dated:
Cheque
D.D.
Month - SEPTEMBER

Total Wages : Rs.
Year - 2011
Interest
Others
Damages
No. of Employees: 7
Rs.
Ps.
1 2 2 5
0 0
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
____________________________________________________________________________________
Bank
Seal
______________________________________
Signature
______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Received Rs.4577.00
For use in Bank

Bank Scroll No. .
Date: .
Bank

QUADRUPLICATE
For Depositor to be attached
with Return of contributions

Region code
5
Employer code
7
Industry
Code
7
Date
Month
Year
Bank & Branch Code*
Name of
Factory /
Estt. &
Address


Cash
Cheque/D.D.No.
Dated:
Cheque
D.D.
Month - SEPTEMBER

Total Wages : Rs.
Year - 2011
Interest
Others
Damages
No. of Employees: 7
Rs.
Ps.
1 2 2 5
0 0
3 3 5 2
0 0
Interest
Damages
Others
Total
4 5 7 7
0 0
____________________________________________________________________________________
Bank
Seal
______________________________________
Signature
______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Received Rs.4577.00
For use in Bank

Bank Scroll No. .
Date: .
Bank


Challan

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EMPLOYEES STATE INSURANCE CORPORATION

Challan Form for Deposit in A/c No. 1

Bank & Branch Code*

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,

Mode of Payment [Tick ()]

Nature of Payment [Tick ()]

* (For Bank Branch Code see on reverse)

For use in Bank

Important: Affix Correct Code No. Name Seal

EMPLOYEES STATE INSURANCE CORPORATION

Challan Form for Deposit in A/c No. 1

Bank & Branch Code*

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,

Mode of Payment [Tick ()]

Nature of Payment [Tick ()]

* (For Bank Branch Code see on reverse)

For use in Bank

Important: Affix Correct Code No. Name Seal

EMPLOYEES STATE INSURANCE CORPORATION

Challan Form for Deposit in A/c No. 1

Bank & Branch Code*

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,

Mode of Payment [Tick ()]

Nature of Payment [Tick ()]

* (For Bank Branch Code see on reverse)

For use in Bank

Important: Affix Correct Code No. Name Seal

EMPLOYEES STATE INSURANCE CORPORATION

Challan Form for Deposit in A/c No. 1

Bank & Branch Code*

M/s.DEVENDRAN COAL INTERNATIONAL PVT LTD,

Mode of Payment [Tick ()]

Nature of Payment [Tick ()]

* (For Bank Branch Code see on reverse)

For use in Bank

Important: Affix Correct Code No. Name Seal

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