Employer’s Code

Region code / Employer code / Industry Code / Date / Month / Year
Name of Factory / Estt. & Address

Mode of Payment [Tick ()]

Cash / Cheque/D.D.No. / Dated:
Cheque / Drawn on (Name of the Bank/Branch)
D.D.
Period of contribution / Month / Year
Nature of Payment [Tick ()] / Regular Contribution / Interest / Damages
Others
Total Wages : Rs.

No. of Employees:

Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………

Total amount (in words) ______

R.O. Demand Letter No. & Date ______

______

Signature

______

Name & Designation – Seal of Authorised Signatory

______

Acknowledgement (to be filled by Depositor)

______

Received Rs. / For use in Bank
(Rs…………………………………………………………………..only) / Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 / Date: ……………………………….
Authorised signature & Seal of the Receiving Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal

and Period of contribution to avoid missing credit

Employer’s Code

Region code / Employer code / Industry Code / Date / Month / Year
Name of Factory / Estt. & Address

Mode of Payment [Tick ()]

Cash / Cheque/D.D.No. / Dated:
Cheque / Drawn on (Name of the Bank/Branch)
D.D.
Period of contribution / Month / Year
Nature of Payment [Tick ()] / Regular Contribution / Interest / Damages
Others
Total Wages : Rs.

No. of Employees:

Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………

Total amount (in words) ______

R.O. Demand Letter No. & Date ______

______

Signature

______

Name & Designation – Seal of Authorised Signatory

______

Acknowledgement (to be filled by Depositor)

______

Received Rs. / For use in Bank
(Rs…………………………………………………………………..only) / Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 / Date: ……………………………….
Authorised signature & Seal of the Receiving Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal

and Period of contribution to avoid missing credit

Employer’s Code

Region code / Employer code / Industry Code / Date / Month / Year
Name of Factory / Estt. & Address

Mode of Payment [Tick ()]

Cash / Cheque/D.D.No. / Dated:
Cheque / Drawn on (Name of the Bank/Branch)
D.D.
Period of contribution / Month / Year
Nature of Payment [Tick ()] / Regular Contribution / Interest / Damages
Others
Total Wages : Rs.

No. of Employees:

Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………

Total amount (in words) ______

R.O. Demand Letter No. & Date ______

______

Signature

______

Name & Designation – Seal of Authorised Signatory

______

Acknowledgement (to be filled by Depositor)

______

Received Rs. / For use in Bank
(Rs…………………………………………………………………..only) / Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 / Date: ……………………………….
Authorised signature & Seal of the Receiving Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal

and Period of contribution to avoid missing credit

Employer’s Code

Region code / Employer code / Industry Code / Date / Month / Year
Name of Factory / Estt. & Address

Mode of Payment [Tick ()]

Cash / Cheque/D.D.No. / Dated:
Cheque / Drawn on (Name of the Bank/Branch)
D.D.
Period of contribution / Month / Year
Nature of Payment [Tick ()] / Regular Contribution / Interest / Damages
Others
Total Wages : Rs.

No. of Employees:

Employees’ Contribution
Employer’s contribution
Interest
Damages
Others
Total………

Total amount (in words) ______

R.O. Demand Letter No. & Date ______

______

Signature

______

Name & Designation – Seal of Authorised Signatory

______

Acknowledgement (to be filled by Depositor)

______

Received Rs. / For use in Bank
(Rs…………………………………………………………………..only) / Bank Scroll No. ………….
In cash /by Cheque/DD No. ………….. Dated………….. Subject to Realisation) Drawn on ……….... (Bank) in favour of ESIC A/c No.1 / Date: ……………………………….
Authorised signature & Seal of the Receiving Bank

*(For Bank Branch Code see on reverse) Important: Affix Correct Code No. Name Seal

and Period of contribution to avoid missing credit

List of the designated Branches of Banks for collection of ESI Contribution

Sl.No / Name of the Bank / Code No. of the Bank / Sl.No / Name of the Bank / Code No. of the Bank
1 / Banashankari II Stage / 6767 / 50 / Chennamma Nagar Belgaum / 7862
2 / Basavanagudi / 3357 / 51 / Bellary / 817
3 / Byatarayanapura (Mys.Road) / 7985 / 52 / Bijapur / 819
4 / Cauvery Bhavan / 3182 / 53 / Channapatna / 7032
5 / City Market / 1989 / 54 / Chitradurga / 5618
6 / Doorvaninagar / 1438 / 55 / Davanagere / 5624
7 / Electronic City / 9044 / 56 / Doddaballapur ADB / 5313
8 / H.A.L. / 1114 / 57 / Dharwad / 833
9 / U.A.S. Hebbal / 1316 / 58 / Gadag / 838
12 / Hoskote ADB / 1808 / 59 / Gulbarga / 3304
11 / Indiranagar / 3301 / 60 / Gokak / 840
12 / Jalahalli / 963 / 61 / Harihar / 7914
13 / Jayanagar IV Block / 4926 / 62 / Hassan / 5622
14 / Bangalore CityBr. (J.C.Road) / 814 / 63 / Hospet / 763
15 / Kumarapark / 1626 / 64 / Hubli / 846
16 / Magadi Road / 9047 / 65 / Mandya / 3916
17 / ITI Anc.Ind. Est Mahadevpura / 3028 / 66 / Lalbaug-Mangalore / 4928
18 / Malleswaram / 7080 / 67 / Panambur-Mangalore / 2249
19 / New Tharagupet / 5794 / 68 / Hampanakatta-Mangalore / 5791
20 / Peenya Indl. Estate / 3024 / 69 / Silver Gate – Mangalore / 7983
21 / Rajajinagar Indl. Estate / 762 / 70 / Munirabad / 5316
22 / Rajajinagar V Block / 3023 / 71 / MysoreMain / 3130
23 / Richard Town / 2263 / 72 / S.K.S. Branch-Mysore (Mysore SSI Branch) / 7968
24 / Shivajinagar / 3298 / 73 / Belavadi Indl. Mysore / 6768
25 / Bangalore Br. (St.Marks Road) / 813 / 74 / Mysore South (Chamundinagar) / 7346
26 / West of Chord Road / 6497 / 75 / Nanjangud / 7916
27 / Wilson Garden / 4932 / 76 / Nargund / 2240
28 / Yeshwanthpur / 3297 / 77 / Nippani / 888
29 / SBI Aircargo Complex / 7130 / 78 / Raichur / 4622
30 / Bidadi / 4235 / 79 / Bankur Indl. Est.Shahabad / 7572
31 / Rajajinagar Commercial Br. / 4230 / 80 / Shimoga / 5619
32 / Doddaballapur Byashattihalli / 8988 / 81 / Tumkur / 3917
33 / J.P. Nagar / 7117 / 82 / Udupi / 945
34 / Karkala (SBM) / 4151 / 83 / Yadgir – ADB / 3764
35 / Kadugodi (SBI) / 5376 / STATE BANK OF MYSORE
36 / KumaraPark SSI Branch / 8577 / 84 / Belagola / 4247
37 / Mysore Commercial Branch / 4161 / 85 / Chamarajanagar / 4162
38 / MICO Layout / 9041 / 86 / Coondapur / 4150
39 / Whitefield (SBM) / 4023 / 87 / Dandeli / 4130
40 / Ramanagar SBI / 4998 / 88 / Hunsur / 4064
41 / Bannerghatta Road / 4407 / 89 / Kanakapura / 4029
42 / ITPL / 4456 / 90 / K.G.F. BEML Nagar / 4168
43 / SSI Branch Peenya / 6506 / 91 / Kollegal / 4065
44 / Kacharakanahalli / 7988 / 92 / Puttur / 4152
45 / Wheel & Axel Plant Yelahanka / 6706 / 93 / Ramanagar / 4031
OUT STATION / 94 / T. Narasipur / 4076
46 / Bagalkot / 812 / STATE BANK OF HYDERABAD
47 / Banhatti / 4757 / 95 / Sedam, Gulbarga District / 2235
48 / Belgaum (Main) / 816
49 / Indl. Estate Belgaum / 2217