Form XXXIV

[See Rule 79(3) (a) & (b)]

UNIFIED ANNUAL RETURN

A. General Part :

(a) Name of the establishment……………………………………………………………........................

Address of the establishment :

House No. /Plot No. ………………… Street Name …………………..............................

Town………………….District…………………….State……………………Pin Code………...........

(b) Name of the employer………………………………………………………………………….............

Address of the employer:

House No. /Flat No. ……………………… Street No. /Plot No. ………………………...

Town………………District…………………State…………………………….Pin Code……….........

E-mail ID………………………Telephone Number……………………Mobile number…………......

(d) Name of the manager or person responsible for supervision and control of establishment

…………………………………………………………………………………………………….............

Address :

House No. /Flat No…………………………Street No./Plot No………………………………….........

Town………………District…………………State…………………………Pin Code…………............

E-mail ID……………………Telephone Number…………………Mobile number……………...........

B. Employer’s Registration/License number under the Codes mentioned in column (2) of the

table below :

Sl.No. Name Registration If yes (Registration

(Yes/No) No.)

(1) (2) (3) (4)

01. The Code on Occupational Safety, Health and

Working Condition Code 2020

02. The Code on Social Security 2020

03. Any other Law for the time being in force

C. Details of Employer, Contractor and Contract Labour:

01. Name of the employer in the case of a contractor’s establishment.

02. Date of commencement of the establishment.

03. Number of Contractors engaged in the establishment during the year.

04. Total Number of days during the year on which Contract Labour was employed.

05. Total number of man-days worked by Contract Labour during the year.

06. Name of the Manager or Agent (in case of mines).

07. Address House No. /Flat No. Street/Plot No. Town

District State Pin Code

E-mail ID Telephone Number Mobile Number

D. Working hours and weekly rest day :

01. Number of days worked during the year.

02. Number of man days worked during the year.

03. Daily hours of work.

04. Weekly day of rest.

E. Maximum number of persons employed in any day during the year :

Sl. Males Females Adolescents (between the Children (below 14 years of

No. ages of 14 to 18 years.) age.)

F. Wage rates (Category Wise) :

Category Rates No. of workers

of

Wages Regular Contract

Male Female Adolescent Children Male Female Adolescent Children

Highly

Skilled

Skilled

Semi-

skilled

Unskilled

G. (a) Details of Payments :

Gross wages paid Deductions Net wages paid

In cash In kind Fines Deductions for damage Others In cash In kind

or loss

(b) Number of workers who were granted leave with wages during the year :

Sl. No. Nature of various welfare amenities provided Statutory (specify the statute)

H. Details of various welfare amenities provided under the statutory schemes:

Sl. No. Nature of various welfare amenities provided Statutory (specify the statute)

I. Maternity Benefit under the Code on Social Security, 2020 :

(a) Details of establishment, medical and para-medical staff :

01. Date of opening of establishment

02. Date of closing, if closed

03. Name of Medical Officer

03(i) Qualification of Medical Officer

03(ii) Is Medical Officer at (the mines or circus)?

03(iii) If a part time, how often does he/she pay visit to

establishment?

03(iv) Is there any Hospital?

03(v) If so, how many beds are provided?

03(vi) Is there a lady Doctor?

03(vii) If so, what is her qualification?

03(viii) Is there a qualified mid-wife?

03(ix) Has any crèche been provided?

(b) Leave Granted under the Code on Social Security, 2020

01. Total number of female employees in the establishment

02. Total number of days of leave granted

03. Number of employees granted maternity leave/benefited by ESI

Declaration : It is to certify that the above information is true and correct and also I certify that I have complied

with the all provisions of Labour Laws applicable to my establishment.

Place Date Signature