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Form guide · Source checked 21 October 2026
ESIC Form 5: return of contributions
A reconciled six-month return field model, with all20 employees and six monthly payments, distinguished from ESIC’s generated online return.
Identified 1950 Regulations form / saved transition and online procedure; checked 21 October 2026
Download and read the completed example
Completed fictional return of contributions for Illustration Office Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001. Synthetic identifiers cannot be used for filing or medical care.
Fictional, unsigned completed illustration. It demonstrates this form’s fields; it is not a filed return, medical opinion, official order or proof of an actual transaction.
When and how this form is used
Regulation26’s printed half-year return has 42 days, plus the separate closure/requisition branches. ESIC’s current employer booklet states this return is generated online from the monthly contributions filed. Do not add an unsupported instruction to file another paper return merely because the historical Form5 layout is available.
Regulation31 and ESIC’s booklet require monthly contributions within15 days after month-end. A half-year return does not extend each month’s payment deadline. The model pays all six monthly liabilities on the10th of the following month.
The prescribed employee list contains paid days, wages, employee contribution, average daily wages, continuing-employment flag and remarks. The employer contribution is reconciled separately. The source’s CA certificate threshold is40 or more total employees; the assumed20-person case must not fabricate a CA sign-off.
The completed fields
Return identity and declaration
| Prescribed field / section | Completed fictional entry |
|---|---|
| Branch / employer code / unit | Appropriate ESIC Branch Office, New Delhi; [synthetic employer code DEMO-ESI; not valid]; Illustration Office Services Pvt Ltd (fictional), 14 Example Park, New Delhi 110001 |
| Principal employer name / designation / home address | Kavita Shah (fictional); director; 8 Example Lane, New Delhi110001 |
| Contribution period / paper due-date field | 1 April–30 September2026; historical Regulation26 half-year paper date11 November2026; current identified return generated online from monthly contributions |
| Employees / employer / total | Employee ₹18,000; employer ₹78,000; total ₹96,000 |
| Return declaration / date | All20 direct covered employees included; contributions assumed correctly paid; no contractor or excluded worker omitted; New Delhi,20 October2026; Unsigned fictional teaching entry; signature, seal, photograph attestation and official issue NOT executed |
Every monthly challan field: date / bank / amount
| Prescribed field / section | Completed fictional entry |
|---|---|
| April2026 | Assumed monthly wages ₹4,00,000; employee ₹3,000 + employer ₹13,000 = ₹16,000; paid 10 May2026 through ESIC-authorised bank [fictional transaction DEMO-01, not a receipt] |
| May2026 | Assumed monthly wages ₹4,00,000; employee ₹3,000 + employer ₹13,000 = ₹16,000; paid 10 June2026 through ESIC-authorised bank [fictional transaction DEMO-02, not a receipt] |
| June2026 | Assumed monthly wages ₹4,00,000; employee ₹3,000 + employer ₹13,000 = ₹16,000; paid 10 July2026 through ESIC-authorised bank [fictional transaction DEMO-03, not a receipt] |
| July2026 | Assumed monthly wages ₹4,00,000; employee ₹3,000 + employer ₹13,000 = ₹16,000; paid 10 August2026 through ESIC-authorised bank [fictional transaction DEMO-04, not a receipt] |
| August2026 | Assumed monthly wages ₹4,00,000; employee ₹3,000 + employer ₹13,000 = ₹16,000; paid 10 September2026 through ESIC-authorised bank [fictional transaction DEMO-05, not a receipt] |
| September2026 | Assumed monthly wages ₹4,00,000; employee ₹3,000 + employer ₹13,000 = ₹16,000; paid 10 October2026 through ESIC-authorised bank [fictional transaction DEMO-06, not a receipt] |
Additional statutory declaration fields
| Prescribed field / section | Completed fictional entry |
|---|---|
| Records / declarations / TICs / PICs / distributed / accidents | Records maintained on assumed facts; new declaration forms0, TICs0, PICs0, distributed0 in this period; all employees already registered; accidents reported0 during April–September. These old card labels are not newly generated portal records. |
| Direct employees covered / wages | 20 employees / ₹24,00,000 |
| Direct employees not covered / wages | 0 / ₹0 |
| Immediate-employer covered / wages | 0 / ₹0; none engaged |
| Immediate-employer not covered / wages | 0 / ₹0; none engaged |
| Wage components included | Monthly salary ₹20,000 per employee: basic ₹14,000 + DA ₹2,000 + other cash allowance ₹4,000; no overtime, bonus or reimbursement in the scenario |
| Wage components excluded | No excluded cash component in this example; employer’s statutory contributions are not employee cash wages |
| Employer truth declaration / CA certificate | Kavita Shah, director; unsigned; CA certificate N/A on the stated total20 employees, below source Form5 threshold40; no false membership number or certification |
Contribution list: every employee and columns1–9
| Prescribed field / section | Completed fictional entry |
|---|---|
| 1. Ravi Kumar (fictional) | IP [synthetic DEMO-0001 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 2. Asha Verma (fictional) | IP [synthetic DEMO-0002 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 3. Neha Das (fictional) | IP [synthetic DEMO-0003 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 4. Arun Mehta (fictional) | IP [synthetic DEMO-0004 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 5. Priya Rao (fictional) | IP [synthetic DEMO-0005 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 6. Rohan Rao (fictional) | IP [synthetic DEMO-0006 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 7. Anita Sen (fictional) | IP [synthetic DEMO-0007 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 8. Kiran Shah (fictional) | IP [synthetic DEMO-0008 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 9. Meera Joshi (fictional) | IP [synthetic DEMO-0009 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 10. Vivek Patel (fictional) | IP [synthetic DEMO-0010 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 11. Sunita Rao (fictional) | IP [synthetic DEMO-0011 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 12. Dev Mehta (fictional) | IP [synthetic DEMO-0012 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 13. Nisha Das (fictional) | IP [synthetic DEMO-0013 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 14. Rahul Sen (fictional) | IP [synthetic DEMO-0014 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 15. Pooja Shah (fictional) | IP [synthetic DEMO-0015 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 16. Amit Joshi (fictional) | IP [synthetic DEMO-0016 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 17. Leena Patel (fictional) | IP [synthetic DEMO-0017 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 18. Sanjay Rao (fictional) | IP [synthetic DEMO-0018 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 19. Maya Mehta (fictional) | IP [synthetic DEMO-0019 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
| 20. Ajay Das (fictional) | IP [synthetic DEMO-0020 in ascending order]; 183 paid days; wages ₹1,20,000; employee contribution ₹900; average daily wages ₹655.74; continues working Yes; remarks: employed before 1 April2026, no joining/leaving in period. Employer signature not executed. |
Totals and official-use fields
| Prescribed field / section | Completed fictional entry |
|---|---|
| Columns4 /5 /6 totals | 3,660 person-days; wages ₹24,00,000; employee contributions ₹18,000 |
| Official entitlement / total check / contribution check | Not determined by this illustration; actual ESIC verification required; no observation memo invented |
| UDC / Head Clerk / Branch Officer countersignatures | All not executed; no official acceptance claimed |
Supporting records and reconciliation
All employee identities and coverage, muster/wage records for each month, portal monthly returns and actual challans, excluded wage support, contractor reconciliation where engaged, generated six-month return and genuine sign-off/CA verification when applicable.
Worked calculation: Per person: six months × ₹20,000 = ₹1,20,000; 0.75%=₹900 EE; 3.25%=₹3,900 ER.20 people: ₹18,000+₹78,000=₹96,000. Person-days20×183=3,660. Average daily wage₹1,20,000÷183=₹655.74 to two decimals.
Official source and version
Download the official source pages containing this form. Adjacent prescribed forms can share a source page; use the heading and rule identified above.
These are the identified ESI (General) Regulations 1950 forms and the online procedures described by ESIC. Code on Social Security section164(2)(b) saves the earlier ESI rules/regulations for one year from commencement to the extent consistent. The 13 July 2026 instrument published in Gazette274902 is expressly a DRAFT inviting objections; it cannot by itself substitute these forms. The examples are source-checked on 21 October 2026 within the identified transition, not a claim that an old paper layout is the current portal screen.
Practical questions
Can I submit the sample as my own completed form?
No. Replace the fictional facts with accurate records, use the competent filing or record-keeping route described above and complete genuine signatures or certifications where required.
What makes the example specific to this form?
A reconciled six-month return field model, with all20 employees and six monthly payments, distinguished from ESIC’s generated online return.