Meeseva Annual Returns Application Form
Download Here Annual Returns Application Form
The Annual Returns Application Form will be like below download the form and fill all the details and attach required documents:
Annual Returns Application Form:
Annual Request Details:-
Factory Registartion Number*: ______
Factory Details:-
Year of Submission of Annual Returns
Applicant Details:-
Aadhaar Card No: ________________
Father Name*: _________________
Locality*:_______________________
District*: ______________ Mandal
Mobile No*: _________________
Service Specific Details:-
Name of the Occupier*:_________________
Name of the Manager*:__________________
Is ESI Employer's Code Available
Is SSI Registration No Available *
Nature of the Industry and the Products manufactured
Large Medium Small
Total Number of Days worked in the Year
Workers Number of working Details
(a ) Average number of Persons employed
Adult Men:
1) Regular:____________ 2)Contract:________________ 3)Casual:____________
Adult Women:
1) Regular:__________ 2)Contract:_______________
Adolescents Children without Certificate of Fitness
1) Regular: __________ 2) Contract
Total Number of days worked in the year:
( b ) Number of Man - Days Worked
Adult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
(c) Total Man Hours worked on over time
Adult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
(d) Total amount of OT Wages Paid
Adult Men:_______________________________ Adult
Adolescents Children without Certificate of Fitness:____________________________________
Is Any Process declared dangerous u/s 87 carried on? If so, Please Mention average no. of
workers employed in each process:
Annual Returns Application Form
_________________
Year of Submission of Annual Returns*: _________________
__________ Name of the occupier*: _________________
___________________ Door No* ____________________________
__________ State *: __________________________________
Mandal*: _________________ Village *: ______
___________
_________________ Address of the Occupier*: ___________________
__________________ Address of the Manager*: __________________
Is ESI Employer's Code Available * Yes No If yes ESI Employer's Code. *:
*: Yes No If yes SSI Registration No. *:
Nature of the Industry and the Products manufactured or Services provided*:
Total Number of Days worked in the Year*: _________________ PAN NO.__________________
Workers Number of working Details :-
) Average number of Persons employed *:
1) Regular:____________ 2)Contract:________________ 3)Casual:____________
1) Regular:__________ 2)Contract:_______________ 3)Casual:____________
Adolescents Children without Certificate of Fitness:
) Contract: _______________ 3) Casual:____________
Total Number of days worked in the year:- ____________________________
Days Worked *:
Adult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
(c) Total Man Hours worked on over time*:
ult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
(d) Total amount of OT Wages Paid*:
Adult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
Is Any Process declared dangerous u/s 87 carried on? If so, Please Mention average no. of
process: __________________________________________
_________________ PAN NO.__________________
1) Regular:____________ 2)Contract:________________ 3)Casual:____________
3)Casual:____________
Casual:____________
Adult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
ult Men:_______________________________ Adult Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
Women :_________________________
Adolescents Children without Certificate of Fitness:____________________________________
Is Any Process declared dangerous u/s 87 carried on? If so, Please Mention average no. of
__________________________________
Salaries Details :
Total Salaries and wages Paid*: ___________
Rate of Percentage of Bonus Paid
Facilities Provided / established as required by the factories Act:
Cooled Drinking Water U/s 18*:
Ambulance Room U/s 45*: Yes
Full Time / Part time / Retainer basis Medical Officer
Shelter / Rest or Lunch Room U/s 47
Fatal / Non fatal Accidents :
Total Number of Fatal Accidents*
Man Days lost due to Non - fatal Accidents
Maternity / Medical Benefits :
No of Cases Maternity Benefits claimed
No of cases Medical bonus claimed
No. of cases leave for miscarriage applied
No. of Cases additional leave for illness applied
No. of Cases additional leave for illness granted
Total Amount of Maternity Benefits paid
Annual Leave details:
No. of workers who were entitled to annual
No. of workers who were allowed to annual leave with the wages during the year
Total amount paid towards annual leave with wages encashment
Authorized Person Details:-
Authorized Name*: __________________
Email Id: ____________________________
Mobile NO*:_____________________
Designationt: _____________________________
Document List:-
Application Form*:
Pan Card of organization/Aadhar Card of the occupier
___________ Total amount of Bonus Paid*: ______________
Rate of Percentage of Bonus Paid*: _______ Total Amount of welfare Fund Contributed
Provided / established as required by the factories Act:
Yes No Safety Officers U/s 45*:
Yes No Canteen U/s 48*: Yes No
/ Retainer basis Medical Officer*: Yes No
Shelter / Rest or Lunch Room U/s 47*: Yes No Welfare Officer U/s 49*:
Fatal / Non fatal Accidents :
*: ________ Total Number of Non fatal Accidents
fatal Accidents*: _________________
Maternity / Medical Benefits :
No of Cases Maternity Benefits claimed*: ______ No of Cases Maternity Benefits paid
No of cases Medical bonus claimed *: ______No of cases Medical bonus paid*: ____________
No. of cases leave for miscarriage applied *: ____ No. of cases leave for miscarriage granted
No. of Cases additional leave for illness applied *: ______________________
No. of Cases additional leave for illness granted*: ___________________________
Total Amount of Maternity Benefits paid*: __________________________________
No. of workers who were entitled to annual leave with the wages during the year
No. of workers who were allowed to annual leave with the wages during the year
Total amount paid towards annual leave with wages encashment*: _______________________
: _____________________________ Relation*: __________________________________
_____________ Delivery Type*: Manual Local
_____________________ Employ Id: _____________________________
_______________________
Pan Card of organization/Aadhar Card of the occupier
Applicant’s Signature