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Ffice Code 3. Employer s Name Current Contributions 4. Contribution's Month (s): From To m m y y m m y 7. Employer Rs Contributions 5. No. of Insured Persons: 6. Total Amount Paid as as Wages/Salaries: y 8. Employee s Contributions Rs Arrears of Contributions 9. Demand & Show Cause No: 10. Date m m y 11. Amount: y Rs 12. Employer s Contribution Arrears for period From: m m y 15. Employee s Contribution Arrears for period From: m m y 13.Employer s Contributions Rs: T.

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