Govt. of India, Ministry of Labour & Employment

Sl. No.	Name	Father’s or husband’s Name	Nature of employ-ment	Rate of wages	Wages earned during the period
Sl. No.	Name	Father’s or husband’s Name	Nature of employ-ment	Rate of wages	Wages earned during the period
1	2	3	4	5	6

Register of deductions for damage or loss caused to the employer by the neglect or default of the employed persons.

Sl. No.

Name

Father’s or husband’s Name

Nature of employ-ment

Damage or loss caused and its value

Whether workmen showed cause against deduction or not, if so, enter date

Sl. No.	Name and address	Days/No. of units worked*	Basic Wages			Lead and lift	Dearness
Sl. No.	Name and address	Days/No. of units worked*	Total	Ordinary	Special	Lead and lift	Dearness
1	2	3	4	5	6	7	8

Other cash payments	Total amount earned	Workman’s contribution to PF	Net amount payable	Other deductions made		Employer’s contribution to PF	Signature or thumb impression or remarks#
9	10	11	12		13	14	15

# If thumb impression is not taken, the signature of the person supervising the payment should be taken.

Note: Columns not applicable to any particular mine may be left unfilled by the employer.

Sl. No.

Class of employees or description of work

Particulars of wage period or the unit of work e.g. per day, per tub etc.

Rate of wages

Rs. P.

Rate of allowances if any

Remarks

S.No.	Name of worker	Design.	Father’s/ husband’s name	No. of units of work done											Total
				S	M		T			W	Th	F	Sat
1	2	3	4	5		6		7	8		9	10		11	12

Annual Return

1.	(a)	Name of the mine, location and postal address					:
	(b)^	Name and address of the Manager/ Contractor					:
	(c)^	Name of the Company/ Firm owning the establishment and full address of its registered office					:
	(d)^	Name and residential address of the Managing Agent/ Director/ Partner in charge of the day to day affairs of the establishment					:
	(e)^	Name and address of the person, if any, other than the manager/ Contractor, who is responsible for payment of wages in terms of the provisio to section 3 of the Payment of Wages Act, 1936					:
2.		Number of days worked during the year					:
3.	(a)*	Number of man-days worked during the year:-
			Persons receiving less than Rs. 200/- per month		Persons receiving Rs. 200/- and more but less than Rs. 1000/- per month
		Adults
		Children
	(b)#	Average daily No. of persons employed during the year:-
			Persons receiving less than Rs. 200/- per month		Persons receiving Rs. 200/- and more but less than Rs. 1000/- per month
		Adults
		Children
	(c)	Gross amount paid as remuneration to persons getting less than Rs. 200/- per month including deductions under section 7(2) is --- of which the amount due to profit sharing bonus is --- and that due to money value of concessions is ---
	(d)	Gross amount paid as remuneration to persons getting Rs. 200/- per month and more but less than Rs. 1000/- including deductions under section 7(2) is --- of which the amount due to profit sharing bonus is --- and that due to $money value of concessions is ---
4.		Total wages paid including deductions under section7(2) on the following account:-
				Persons receiving less than Rs. 200/- per month		Persons receiving Rs. 200/- and more but less than Rs. 1000/- per month
	(a)	Basic wages including overtime wages and non- profit sharing bonus
	(b)	Dearness and other allowances in cash

	(c)	Arrears of pay in respect of previous year paid during the year
5.		Number of cases and amount realized as:-
				Persons receiving less than Rs. 200/- per month		Persons receiving Rs. 200/- and more but less than Rs. 1000/- per month
				No. of cases	Amount	No. of cases	Amount
	(a)		Fines
	(b)		Deductions for damage or loss
	(c)		Deductions for breach of contract
6.			Disbursement of the fines fund:-
			Purpose		Amount
	(a)
	(b)
	(c)
	(d)
7.			Balance of fines fund in hand at the end of the year:

obtained by dividing the aggregate number of attendances during the year by the number of working days.

$ Money value of concessions should be obtained by taking the difference or the cost price paid by the employer and the actual price paid by the employee for supplies of essential commodities given free or at concessional rates.

I have to furnish the following particulars in respect of*……………. at ………….. mine of …………… (owner)……………….. :

4. Date on which it is intended to open/ reopen/ abandon/ discontinue(+) the mine

5. Actual date of opening/ reopening/ abandonment/ discontinuance(+) of mine

# To be filled in only when the notice refers to a change and only against the item

Fines				Remarks
Acts or omissions for which fine imposed	Whether workmen showed cause, if so enter date	Date and amount of fine imposed	Date on which fine is realized	Remarks
7	8	9	10	11

Date of disbursement	Amount disbursed	Purpose for which amount disbursed	Remarks
1	2	3	4

Name of the person in whose presence a workman’s explanation is heard in respect of an employee engaged by a contractor	Date and amount of deduction imposed	Number of installments, if any	Date on which total amount realized	Remarks
7	8	9	10	11

Sl. No.	Name	Father’s name or husband’s name	Nature of employment	Earnings during a wage period	Date and amount of advance
1	2	3	4	5	6

Purpose(s) for which advance made	No. of installments by which advance to be repaid	Amount of installments repaid with dates of postponement granted	Date on which total amount paid	Signature or thumb impression of the worker or remarks
7	8	9	10	11