Delhi Labour Welfare Board 
Statement of employees' and employers' contribution for the six months ending on the 30th June and the 31st December, respectively
[See Rule 3(4)]
Annexure
| Sr.No. | Description |
|---|---|
| 1. | Name of the establishment |
| 2. | Name of the employer |
| 3. | Class of establishments (i.e. whether a factory of motor omni bus service, a shop, commercial establishment, residential hotel, restaurant, eating house, theatre or other place of public amusement or entertainment). |
| 4. | Address of the establishment |
| 5. | Total number of employees whose names stands on the establishment register on the 30th June/the 31st December. |
| 6. | (a)Employees' contribution at the rate of Rs._________ (b)Employers' contribution at the rate of Rs. _________ Per employee, |
| 7. | Total of sub-entries (a) and (b) of entry 6. |
| 8. | Weather the contribution has already been paid to the Welfare Commissioner, if so, whether by cheque, money order or cash and details thereof. |