Form XXXVIII

[See sub-rule (1) and sub-rule (2) of Rule 90]

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........................pincode.........

A.

b. Name of the employer.......................................................................................... Address

of the employer:

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

No. .............................. Town......................District.........................State..................................pincode.........

e-mail ID.................................Telephone Number...............Mobile number.............

A.

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

of establishmen.................................................................................

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 of the Code Details of registration (if any)

registration no. year

1 2 3 4

1 The Code on Occupational Safety Health and working condition code 2020.

2 The Code on Social Security 2020.

3 Any other Law for the time being in force.

C. Details of Employer, Contractor and Contract Labour:

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

2 Date of commencement of the establishment.

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

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

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

D. Working hours and weekly days rest-

1 Number of days worked during the year.

2 Number of man-days worked during the year.

3 Daily hours of work.

4 Weekly day of rest.

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

S. No Males Females Adolescents (between the age of 14 to 18 Children (below 14 years of Total

years.) age.)

F. Wage rate (category wise)

Category Rates of wages No. of workers

Regular Contract

Male Female Adolescent Children Male Female Adolescent Children

Highly

skilled

Skilled

semi- skilled

un-skilled

G. Details of payments:

Gross wage paid Deductions Net wages paid

In cash In kind Fines Deductions for damages or loss Others In cash In kind

H. Number of workers who were granted leave with wages during the year:

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

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

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

provided

J. Leave granted as Maternity benefits under the Code on Social Security, 2020:

1 Total number of female employees in the establishment

2 Total number days of leave granted

3 Number of employees granted maternity leave/benefited by ESI

Declaration

It is to certify that the above information is true and correct and I also certify that I have come

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

Date:

Place:

Signature of employer/

Authorized signatory

Seal (if any)