FORM A
[See section 4 (1) proviso (a)]
CORE RETURN
RETURN FOR THE YEAR ENDING 31ST DECEMBER
(To be furnished on or before the 15th February of the succeeding Year by small establishments and very
small establishments)
1. (a) Name and postal address of the establishment.
(b) Name and residential address of the employer.
(c) Name and residential address of the Manager or person responsible for supervision and control
of the establishment.
(d) Name of the principal employer in the case of a contractor‟s establishment.
(e) Date of commencement of the establishment.
NATURE OF OPERATION/ INDUSTRY /WORK CARRIED ON
2. (a) Number of days worked during the year.
(b) Number of man-days worked during the year.
(c) Daily hours of work.
(d) Day of weekly holiday.
3. (a) Average number of persons employed during the year.
(i) Males.
(ii) Females.
(iii) Adolescents (those who have completed 14 years but have not completed 18 years of age).
(iv) Children (those who have not completed 14 years of age).
(b) Maximum number of workers employed on any day during the year.
(c) Number of workers discharged, dismissed, retrenched or whose services were terminated
during the year.
4. Rates of wages—category wise:
(1) Males (2) Females (3) Adolescents (4) Children
5. Gross wages paid:
(a) in cash
(b) in kind.
6. Deductions:
(a) Fines.
(b) Deductions for damage or loss.
(c) Other deductions.
7. Number of workers who were granted leave with wages during the year.
8. Nature of Welfare amenities provided: Statutory (specify the Statute).
6
9. Does the establishment carry out any hazardous process or dangerous operation coming within the
meaning of the Factories Act, 1948. If so, give particulars.
10. Number of Accidents:
(a) Fatal.
(b) Non-fatal.
11. Nature of safety measures provided as required under the Factories Act, 1948.
Signature of the employer with full name in capitals.
Date………………….
Place...........................
FORM B
(See section 4 (1) proviso (b) (i)]
REGISTER OF WAGES REQUIRED TO BE MAINTAINED BY SMALL ESTABLISHMENTS
(To be maintained within seven days of the expiry of the wage period)
Name of establishment_________________ Name and address of employer__________________
Address (Local) ______________________ Nature of work_______________________________
(Permanent) _________________________ Wage period ________________________________
Serial
Number
Name of
the
employee
Sex Designation Classification,
whether permanent/
temporary/casual/
part-time or any other
Father‟s
or
husband‟s
name
Total days/number of
units worked
1 2 3 4 5 6 7
DEDUCTIONS
Advances Fines due to damage or
loss by neglect or default
Provident Fund Employees‟ State Insurance
Employers‟
contribution
Employees'
contribution
Employers‟
contribution
Employees‟
contribution
17 18 19 20 21 22
DEDUCTIONS
Other deductions
indicating the nature
Total
deductions
Net amount
payable
Signature or thumb
impression of
employee with date
Signature of
Inspector with date
Remarks
23 24 25 26 27 28
Wages earned
Basic wage Dearness
allowance
Overtime Bonus or
exgratia
Maternity
benefits
Gratuity Any other
allowance Total
amount Statutory
Minimum
rate
Actual
8 9 10 11 12 13 14 15 16
8
Notes: 1. In case of deduction of any advance taken by an employee, the employer shall also indicate
therein the number of instalments paid/total instalments by which advance is to be repaid such as
“5/20, 6/20” etc. The purpose of advance shall also be mentioned in the Remarks column.
2. In case of imposition of fines or deduction for damage or loss, the specific act or omission for
which the penalty has been imposed has to be indicated in the Remarks column. A certificate
shall also be recorded in the said column to the effect that an opportunity to show cause was
given to the employee concerned before imposition of fine or deduction.
Signature of the employer with full name in capitals.
Date………………………
Place……………………..
FORM C
[See section 4 (1) proviso (b) (i)]
MUSTER ROLL TO BE MAINTAINED BY SMALL ESTABLISHMENTS
Name of establishment_________________ Name and address of the employer___________________
Address (Local_______________________ _______________________________________________
(Permanent__________________________ Wage period____________________________________
Total
overtime
worked1
Total production in
case of piece-rated
workers2
Compensatory rest3
Signature of Inspector
with date
Remarks
Brought forward
from previous
wage period
Given during the
wage period
9 10 11 12 13 14
Notes: 1. In the case of daily-rated workers, the extent of overtime done on each occasion has to be
reflected against each concerned date, such as “P/1” meaning “Present with one hour‟s
overtime”, “P/1-2” meaning “Present with one and a half hour‟s overtime”, and so on.
2. The number of units of work done by a piece-rated worker has to be noted for each day in the
Register. In case of employment of any child/adolescent, the employer shall indicate the hours
worked each day with intervals of rest.
3. The compensatory rest availed by the worker has to be marked in the Register in red ink as
„CR‟.
4. Column 7 to be filled up on each working day and the remaining columns to be completed
within seven days of the expiry of the wage period.
Signature of the employer with full name in capitals.
Date………………………
Place………………………
Serial
Number
Name of
the
employee
Date of
employment
Permanent
address
Age
or
date
of
birth
Father‟s or
husband‟s
name
For the period
ending ____
Number of units of
work done during
____
Total
attendance
FORM D
[See section 4 (1) proviso (b) (i)]
MONTHLY REGISTER SHOWING WELFARE AMENITIES TO BE MAINTAINED BY SMALL ESTABLISHMENTS
Name and address of the
employer_________________
Address of the establishment:
Local/ Permanent
For the month of________________
Whether Welfare Amenities
provided for
Whether Scheduled
Caste/Scheduled
Tribe, Handicapped,
or any other
particular category
Signature of
the employer
or his agent
Remarks of the
Inspecting
Officer
Signature of
Inspector with
date Rest
room
Drinking
water
First aid
10 11 12 13 14 15 16
Note: To be completed within seven days of the expiry of each calendar month.
Signature of the employer with full name in capitals.
Date………………………
Place………………………
Serial
Number
Name of
the
employee
Sex Designation Weekly day
of rest
Dates of
holidays for
festivals or
similar other
occasions
Number
of casual
leave
availed by
the
employee
Quantum of
annual leave
with wages
Due Availed
1 2 3 4 5 6 7 8 9
FORM E
[See section 4 (1) proviso (b) (ii)]
MONTHLY REGISTER OF MUSTER ROLL-CUM-WAGES REQUIRED TO BE MAINTAINED BY VERY SMALL
ESTABLISHMENTS
Year_________________
Month______________ or
Wage period
(where different)________
Name of establishment___________________________________________________
Name of employee__________________________ Father‟s Name________________________
Nature of work_____________________________ Rate of wages________________________
Wage period_______________________________ Date of employment___________________
Date Hours of work Interval for Rest
and Meal
Hours worked
with the employer
Overtime Casual or sickness
leave availed
during the
month/wage
period
From To From To Hours
worked
Wages
earned
1 2 3 4 5 6 7 8 9
Note: Columns 1 to 12 to be filled up on each working day and the remaining columns to be completed
within seven days of the expiry of the wage period.
Signature of the employer with full name in capitals.
Date………………………
Place………………………
Privilege Leave Signature
of the
employer
Remarks
of the
employer
Remuneration Due
Leave
Due
Leave
availed
Balance Basic
salary or
wage
Overtime Other
allowances,
if any
Total
10 11 12 13 14 15 16 17 18
Deductions Net amount
of payment
Date of
payment
Signature or
thumb
impression of
the employee
Signature
of
Inspector
with
remarks,
if any,
and date
Fines and
deductions
on account
of damage
or loss by
neglect or
default
Other
deductions
Advance paid, if any
Date Amount Total