FORM - 6                             
                                               RETURN OF CONTRIBUTION (REGULATION-26)                                               
              EMPLOYEE'S STATE INSURANCE CORPORATION              

Name of the Factory/Establishments :

                                                              ESI CODE NO. : 
							      LOCAL OFFICE : 
NEW DELHI - 03.                                            NO.OF EMPLOYEES : 
DELHI 110003                                           FOR THE PERIOD FROM : 
Page No.:    1                                         

Particulars of Principal Employers :
Name                :                                         
Designation         :                                         
Residential Address :                                         
                    :                                         
I  furnish below the details of the  employer' and  employee's  share of contributions  in respect of the under mentioned insured
persons.  I hereby declare that the return includes every employee,  employed directly  or through an immediate employer in or in
connection with the work of the factory /establishment or any work connected with the administration of the factory/establishment
or purchase of the raw materials  sale or distribution of furnished products etc.  to whom the contribution period  to which this
return relates,   applies and that the  contributions in respect of employer's  and employee's  share have been correctly paid in
accordance with the provisions of the act and regulations relating to the payment of contributions vide challans detailed below:-


Employer's Contribution :	        Employee's contribution :               Total contribution :

(1) Challan Dated -   -  -              for Rs.     0.00
(2) Challan Dated -   -  -              for Rs.     0.00
(3) Challan Dated -   -  -              for Rs.     0.00
(4) Challan Dated -   -  -              for Rs.     0.00
(5) Challan Dated -   -  -              for Rs.     0.00
(6) Challan Dated -   -  -              for Rs.     0.00
(7) Challan Dated -   -  -              for Rs.     0.00
                             Total.......         0.00



PLACE : DELHI                                                                                SIGNATURE : 


Date                                                                                  DESIGNATION :Prop./Partner/Director/Auth.Sign.


====================================================================================================================================
SNo.| INSURANCE No.  | NAME OF THE INSURED     |   NO.OF|  AMOUNT OF|  EMPLOYEE|   AVERAGE|IsWOR| DATE OF  | DATE OF  | REMARKS
    |                | PERSON                  |    PAID|  SAL/WAGES|     CONT.|     DAILY|UNDER| APPOINT. | LEFT     | DISPENSARY
    |                |                         |    DAYS|           |          |     WAGES|  ESI| DD/MM/YY | DD/MM/YY |
    |                |                         |        |   ( Rs.P.)|  ( Rs.P.)|  ( Rs.P.)|WAGES|          |          |
====================================================================================================================================
                                               |        |           |          |          |     |          |          |
                                               |        |           |          |          |     |          |          |
                                               |        |           |          |          |     |          |          |
                	                       |        |           |          |          |     |          |          |
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                *** TOTALS ***                 |        |           |          |          |     |          |          |
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PLACE : DELHI                                                                                SIGNATURE : 


Date                                                                                  DESIGNATION :Prop./Partner/Director/Auth.Sign.