Form XXII

[(See Rule 27(3)(a)]

Unified Annual Return

A. General Part:

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

Address of the establishment:

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

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..........……

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

establishment…………………………………………………………………………

…

Address:

House No./FlatNo…………………….Street No./ Plot No………………………

Town………………….District…………………….State………….Pin code…...........

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

number…..................

B. Employer’s Registration/Licence number under the Codes mentioned in column

(2) of the table below:

S. No. Name Registration If yes (Registration No.)

S.No. Name Registration If yes (Registration No.)

1 2 3 4

The Code on Occupational

01. Safety Health and

Working Code, 2020

The Code on Social

02

Security 2020.

Any other Law for the

03

time being in force.

C. Details of Employer, Contractor and Contract Labour:

Name of the employer in the case of a contractor’s

01.

establishment.

02. Date of commencement of the establishment.

Number of Contractors engaged in the establishment during

03.

the year.

Total Number of days during the year on which Contract

04.

Labour was employed.

Total number of man-days worked by Contract Labour

05.

during the year.

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

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

No

07 District State Pin Code

E-mail ID Telephone Number Moblie Number

D. Working hours and weekly rest day:

01. Number of days worked during the year.

02. Number of mandays 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:

Adolescents

Sl. (between the

Males Females Total

No. age of 14 to 18

years.)

F. Wage rates (Category Wise):

Rates No. of workers

Category of Regular Contract

Wages Male Female Adolescent Male Female Adolescent

Highly

Skilled

Skilled

Semiskilled

Unskilled

G. (a) Details of Payments:

Gross wages paid Deductions Net wages paid

Deductions for damage or

In cash In kind Fines Others In cash In kind

loss

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

Sl. No. During the year Number of workers Granted leave with wages

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 close

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 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.

Sign. Here

Place

Date