EMPLOYEES' STATE INSURANCE CORPORATIONChallan Form for Deposit in A/C No. 1 Date Month Year EMPLOYEES' STATE INSURANCE CORPORATION Challan Form for Deposit in A/C No. 1 0 Date Month Year Employer's Code Name of Factory/Estt. & Address Bank & Branch Code Employer's Code Name of Factory/Estt. & Address 0 Bank & Branch Code 0 0 0 Cash …….. Cheque … *…. D.D. …….. Dated Period of Contribution 0 Mode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Details of Payment [Tick (p ) mode used] No. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total 0 Cash …….. Cheque …*…. D.D. …….. Dated Period of Contribution Mode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Details of Payment [Tick (p ) mode used] No. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total Regular Contribution……. Interest ……… Damages …….. Others ……… Regular Contribution……. Interest ……… Damages …….. Others ……… Total Wages 0 0 0 Total Wages 0 0 Total amount (in words) #R.O. Demand Letter No. & Date Total amount (in words) #R.O. Demand Letter No. & Date 0 Signature __________________________________________ Name & Designation - Seal of Authorised Signatory Signature __________________________________________ Name & Designation - Seal of Authorised Signatory (Acknowledgment) (to be filled by Depositor) Received Rs. (Rs. ______________________________________________ Only) In Cash/by Cheque/DD No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 For use in Bank Bank Scroll No. ……………. Dated ……………………….. Authorised Signature & Seal of the Receiving Bank (to be filled by Depositor) (Acknowledgment) For use in Bank Bank Scroll No. ……………. Dated ……………………….. Authorised Signature & Seal of the Receiving Bank Received Rs. (Rs. ______________________________________________ Only) In Cash/by Cheque/DD No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No.1 . . . . . Cheque …*….. Dated Period of Contribution JANUARY 2009 M ode of Payment [ Tick (p ) mode used] Cheque/DD No.Seal of Authorised Signatory S ignature __________________________________________ Name & Designation . Authorised Signature & Seal of the Receiving Bank (to be filled by Depositor) (Acknowledgment) For use in Bank Bank Scroll No. Others ……… Regular Contribution…….. Cheque …*…. Dated ……………………….. 1 0 …………….O. Demand Letter No.D. & Address M ode of Payment [ Tick (p ) mode used] Cheque/DD No. Drawn on (Name of the Bank). Date M onth Year Employer's Code Bank & Branch Code Employer's Code Bank & Branch Code 0 0 0 Cash ……. Drawn on (Name of the Bank).D. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total Regular Contribution……. Dated Period of Contribution Name of Factory/Estt. D. of Employees Employees Contribution Employer's Contribution #Interest #Damages #Others Total 0 Cash ……..O. ……………. ______________________________________________ Only) In Cash/by Cheque/DD No.. ……. Others ……… Total Wages 0 0 0 Total Wages 0 0 Total amount (in words) #R.Seal of Authorised Signatory (Acknowledgment) (to be filled by Depositor) Received Rs. & Date S ignature __________________________________________ Name & Designation .EMPLOYEES' STATE INSURANCE CORPORATION Challan Form for Deposit in A/C No. (Rs. D. Demand Letter No. Details of Payment [Tick (p ) mode used] No.. Dated ………………………. Details of Payment [Tick (p ) mode used] No. ……………. Interest ……… Damages ……. M onth Year EMPLOYEES' STATE INSURANCE CORPORATION Challan Form for Deposit in A/C No. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No. & Address Name of Factory/Estt. Dated (subject to Realisation) drawn on (Bank) in favour of ESIC A/C No. 1 Date ……………. ______________________________________________ Only) In Cash/by Cheque/DD No.. & Date Total amount (in words) #R.1 .. ……. Authorised Signature & Seal of the Receiving Bank Received Rs...1 For use in Bank Bank Scroll No. Interest ……… Damages ……. (Rs.