Application for recognition of provident fund under Part-A of the Schedule XI to the Act

Part-A

1.

Details of the employer

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

(iii)

Permanent Account Number

(iv)

Business/Profession

(v)

Principal place of business

(refer Note 2)

(vi)

Total number of employees

(vii)

Number of employees employed in India

Part -B

2.

Details of the establishment

(i)

Name

(ii)

Whether covered under Employees’ Provi-

dent Fund and Miscellaneous Provisions Act, 1952 (EPF and MP Act)

(i) Yes

(ii) No (choose one)

(iii)

If response to row No. 2(ii) is Yes, whether covered under section

(i) 1(3) of EPF & MP Act

(ii) 1(4) of EPF & MP Act

(choose one)

(iv)

Whether exempt under section 17 of the EPF and MP Act

(i) Yes

(ii) No (choose one)

(v)

If response to row No. 2(iv) is Yes, please indicate relevant:

(a)

Order number

(refer Note 3)

(b)

Date of Order

dd/mm/yyyy

(vi)

If response to row No. 2(iv) is No, please indicate relevant:

(a)

Date of application with Employee Provident Fund Organisation

dd/mm/yyyy

(b)

Status of the application

(i) Rejected

(ii) Pending

(select one)

Part-C

3.

Details of the Fund

(i)

Name

(refer Note 1)

(ii)

Permanent Account Number

(iii)

Date of creation

4.

Number of employees subscribing to the fund

(i)

In India

(ii)

Outside India

5.

Place where the accounts of the funds are or will be maintained

(refer Note 2)

6.

Number of trustees of the fund

7.

Details of the trustees

Sl.No.

Name of

the Trustee

Permanent

Account

Number

Address

of the

Trustee

1.

(refer Note

1)

(refer

Note 2)

2.

(refer Note

1)

(refer

Note 2)

8.

Whether it is an irrevocable trust

(i) Yes

(ii) No (select one)

9.

If response to row No. 8 is No, the reasons thereof

10.

Details of contribution as a percentage of employee’s salary by:

(i)

employee

(ii)

employer

(iii)

employer (proposed)

11.

Whether the fund was recognized under the Income- tax Act, 1961 before 31.03.2006

(i) Yes

(ii) No (select one)

12.

If response to row No. 11 is Yes, please indicate the date of approval

dd/mm/yyyy

13.

If the fund is already in existence, details relevant to the financial year ending prior to the date of application

(i)

Total corpus of the fund

(ii)

Investment pattern being followed

[give breakup in accordance with the invest- ment pattern prescribed in rule 292]

Part-D

14.

Whether the establishment has an approved super- annuation fund

(i) Yes

(ii) No (select one)

15.

If response to row No. 14 is Yes, please indicate relevant

(i)

Order number

(refer Note 3)

(ii)

Date

dd/mm/yyyy

(iii)

Authority which has granted approval

16.

Whether the establishment has an approved gratuity fund

(i) Yes

(ii) No (select one)

17.

If response to row No. 16 is yes, please indicate the:

(i)

order number

(refer Note 3)

(ii)

date of order

dd/mm/yyyy

(iii)

authority which has granted approval

18.

Other details to be provided as separate enclosure

(Attach as per note 4)

VERIFICATION

I/We, …………… the trustees of the above-named fund, solemnly declare that the information given in the application is true and correct to the best of my/our information and belief and that the documents sent here- with are true copies of the originals.

Signature:

Annexure

Particulars

A-1

A copy of the trust deed (refer sub-rule (1) of rule 296)

A-2

A copy of the rules of the fund (refer sub-rule (1) of rule 296)

A-3

Documentary Proof if the establishment is exempt under section 17 ofthe EPF and MP Act (refer row No.2(iv) and (v))

A-4

Proof of receipt from Employees Provident Fund Organization if the establishment is not exempt under section 17 ofthe EPF and MP Act (refer row No. 2(vi))

A-5

Copy of letter of approval if the fund was recognized under the Income-tax Act, 1961 be- fore 31.03.2006 (refer row No. 12)

A-6

A copy of the balance-sheet of the fund, relevant to the financial year ending prior to the date of application, if the fund is already in existence. (refer row No.13)