Form XXIII

[(See Rule 39 (3)(a) (b)]

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./Flat No……………………………. 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:

If yes (Registration

S. No. Name Registration

No.)

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

The Code on Occupational Safety Health and working

01.

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:

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

03.

during the year.

Total Number of days during the year on which

04.

Contract 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 No……………...Street/Plot No……….. Town……………..

07. 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 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. Children (below 14

Males Females (between the age of Total

No. years of age.)

14 to 18 years.)

F. Wage rates (Category Wise):

No. of workers

Rates of

Category Regular Contract

Wages

Male Female Children Adolescent Male Female Children Adolescent

Highly

Skilled

Skilled

Semiskilled

Unskilled

G. (a) Details of Payments:

Gross wages paid Deductions Net wages paid

In cash Deductions for

In kind Fines Others In cash In kind

damage or 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 closed

03. Name of Medical Officer

03(i) Qualification of Medical Officer

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

If a part time, how often does he/she pay visit to

03(iii)

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.

Place Date Sign. Here