Name and address of contractor

_______________________________

Name and address of establishment in / under which contract is carried on ___________________________________

Nature and location of work

_______________________________

Name and address of Principal employer ___________________________________

Sl. No.

Name of workman

Father's / husband's name

Designation/ nature of employment

Particulars of damage or loss

Date of damage or loss

Whether workman showed cause against deduction

1

2

3

4

5

6

7

Name of person in whose presence employee's explanation was heard

Amount of deduction imposed

No. of installments

Date of recovery

Remarks

First installment

Last installment

8

9

10

11

12

13