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. 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:

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

If Yes,

S.no Name Registration

(Registration No.)

1 2 3 4

01 The code on Occupational Safety Health and Working

02 The Code on Social Security 2020

03 Any other Law for the Time being

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).

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

07 District State Pin Code

E-mail ID Tel Number Mobile Number

D. Working Hours and Weekly rest day:

01 Number of days worked during the year

02 Number if mandays worked during the year

03 Daily hours of work

04 Weekly day of rest

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

Sl. Adolescents (between Children (below

Males Females Total

no. the age of 14 – 18 years) 14 years of age)

F. Wage rates (Category Wise)

Rate No. of workers

Category of Regular Contract

Wages Male Female Children Adolescent Male Female Children Adolescent

Highly

Skilled

Skilled

Semiskilled

Unskilled

G. (a) Details of Payment:

Gross wage paid Deduction Net wages paid

Deduction 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:

Statutory

Sl.no Nature of various welfare amenities provided

(specify the statute)

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

(a) Details of the establishment, medical and Para-Medical staff:

01 Date of opening of the 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) Is 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 creche been provided?

(b) Leave Granted under the Code of 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.

Signature

Place:

Date: