Form IV

(See clause (ii) of Sub-rule (1) of Rule 42)

REGISTER OF WAGES, OVERTIME, ADVANCES, FINES AND

DEDUCTIONS FOR DAMAGE AND LOSS

Name of the Establishment

Name of the Employer

Name of the Owner

PAN/TAN of the Employer

Registration Number of the establishment (LIN/UIN Number shall be the

Registration Number of the Establishment)

Sl. Sr. No. in Name Desig Depar Duration of Wag Total Total Rate of wages

No. Employee of the nation tment Payment of e no. overtim

Register/ emplo wages Perio of e Basic DA Allow

Employee yee (Monthly/ d days hours ances

Code Fortnightly/ Fro work worked

Weekly/ m- ed or

Daily To duri overtim

/Piece ng e

rated) the product

wage ion in

perio case of

d piece

workers

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)

Amount of wages earned Deductions Net

Pay

men

t

Basi DA Allo Ove Total E E Soci Incom Insur Ad Recov Reco Ot Total

c wa r wages P SI ety e ance va ery very her Dedu

nce tim earned F C Tax nce of on s ction

s e s Fine acco s

unt

of

Dam

ages

/

Loss

es

(13) (14) (15) (16) (17) (1 (1 (20) (21) (22) (23 (24) (25) (26 (27) (28)

8) 9) ) )

Date of Receipt by Nature of Amount Damage or Signature of

Payment employee/Bank acts of fine loss Employer/Employer

transaction ID and imposed caused to Representative*

omissions the

for which employer

fine by

imposed neglect or

with default

date of the

employee

(29) (30) (31) (32) (33) (34)

*Note: Required in case register is maintained physically.