FORM ‘’U”
COMBINED ANNUAL RETURN
[See Rule 24(9-C) Of The Karnataka shops and Commercial Establishment Rules, 1963]
in lieu of
1. Form XXV of Rule 82(2) of the Contract Labour (Regulation and Abolition) (Karnataka)
Rules, 1974.
2. Form III of Rules 22(4) of the Karnataka Minimum Wages Rules, 1958.
3. Form XX of Rules 20(1) of the Karnataka Payment of Wages Rules, 1963.
4. Form L of Rule 16 of the Karnataka Maternity Benefit Rules , 1963.
1. Name Of The Establishment
2. Full Postal Address
Location Address Telephone Fax E-Mail
1. Establishment
2. Registered Office/Head Office
3. Name And Residential Address of the Employer Or A person responsible for
Conduct and Control Of The Business:
___________________________________________________________________________
4.Name And Residential Address Of The Manager/Authorised Signatory:
Name - Loveena Renita Monteiro
Designation
Residential Address
Telephone Moblie
E-Mail
5) Nature Of Business Of The Establishment
6-A. Particulars Of Employment:
No.Of
Persons On No.Of No.Of No.Of Man No Of Man Hours Worked Total Amount
Roll As On Persons Days Days Worked Including O T During The Year Of
1-1-200…. On Roll Worked During The Year Salary/Wages
(Beginning As On Paid
Of The 31-12- Including O T
Year) 200(At Wages and
The Allowances
End Of
The
Year) Men Women Total Men Women Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
6-B, No Of Employees Whose Employment Is Ceased:
No. Of Employees Amount Of No.Of Employees Amount Of
Discharged/Dismissed Compensation Paid Suspended During Subsistence
Terminated/Retrenched/Resigned/Ret The Year Allowance
ired During The Year Paid
(1) (2) (3) (4)
1. Particulars Of Earned Leave With Wages:
FORM – U- KARNATAKA SHOPS & COMMERCIAL ESTBLISHMENTS RULES, 1963
___________________________________________________________________________
Category of Total No. of No.of No. of No. of employees
Employees persons employees employees paid wages/salary
employed eligible for availed/granted in lieu of earned
earned leave earned leave leave
(1) (2) (3) (4) (5)
(i) Men
(ii) Women
2. Whether the following welfare measures are provided?
(1) Canteen Yes/No/Not applicable
(2) Creches Yes/No/Not applicable
(3) Shelters, Rest rooms
and Lunch rooms Yes/No/Not applicable
(4) Transport facility Yes/No/Not applicable
3. Maternity Benefits
9-A. Particulars of Maternity Benefits:
1. Total No. of women workers who worked for a
period of 160 days in the last 12 months immediately
preceding the date of delivery
2 No. of women workers discharged/dismissed in the
last 12 months
3 No. of women workers for whom prenatal
confinement and post-natal confinement is provided
by the employer with free of cost
4 No. of women workers died
(a) Before delivery
(b) After delivery
9-B. Leave/additional leave details:
No. of women
Item Leave sanctioned Leave rejected
applied for leave
Miscarriage
Illness (additional leave
under Section 10)
9-C. Maternity Benefit paid:
Item No. of claims No. of leaves No. of claims Total benefit
received sanctioned rejected paid in rupees
Confinement
Miscarriage
Illness
Medical Bonus
82 KARNATAKA SHOPS & COMMERCIAL ESTBLISHMENTS RULES, 1963
___________________________________________________________________________
4. Particulars of deductions made from salary (wages)
No. of employees involved Total amount of deduction
Made
(i) Fines
(ii) Damages/Loss
(iii) Breach of Contract
(iv) Others
Total
5. Contract Labour:
Names Period of contract Nature of No. of No. of No. of man
and work contract days days worked
address of workmen worked
the employed
contractor From To
s
(1) (2) (3) (4) (5) (6) (7)
Total
Certified that the information furnished above to the best of my knowledge and belief, is
correct.
Signature of employer/Manager/
Authorised signatory
Date: Name (IN CAPITALS) ………
Place: Designation ……………….].
_________
