Form IV

(See rule 43)

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

(Labour Identification Number (LIN) shall be

the Registration Number of the Establishment)

Sr. No. in Name Designa Department Duration of Wage Total Total Rate of wages

Employee of the tion Payment of Period no. of overtime

Sl. No. Basic DA Allow

Register/ employee wages From- days hours

ances

Employee (Monthly/ To worked worked or

Code Fortnightly/We during overtime

ekly/ the production

Daily/Piece wage in case of

rated) period piece

workers

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

Amount of wages earned Deductions Net

Paym

Basic DA Allow Over Total EPF ESIC Society Income Insurance Others Recovery Recovery Total

ent

ances time wages Tax of Fine on account Deductions

earned of

Damages/

Losses

(13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27)

Date of Payment Receipt by Nature of acts and Amount of fine Damage or loss caused to the Signature of

employee/Bank omissions for which fine imposed employer by neglect or default Employer/Employer

transaction ID imposed with date of the employee Representative*

(28) (29) (30) (31) (32) (33)

*Note: Required in case register is maintained physically.