Form XV — Register for Wages, Overtime and Deductions

Rule: Rule 72(1)(iii) · Signed by: Manager · Under: OSH & Working Conditions (Central) Rules 2026

What the form records

• Name of Establishment
• Name of the Employer/owner
• PAN/TAN of the Employer
• Registration Number of the establishment (LIN)
• Wage Period from dd/mm/yyyy to dd/mm/yyyy (Monthly/Fortnightly/Weekly/Daily/Piece Rated)
• Serial Number
• Employee Code Number
• Name of the employee
• Designation
• Department
• Duration of Payment of wages (Monthly/Fortnightly/Weekly/Piece rated)
• Wage Period from- to
• Total number of days worked during the wage period
• Total overtime hours worked or overtime production in case of piece workers
• Rate of Wage - a) Basic
• Rate of Wage - b) DA
• Rate of Wage - c) Other allowance
• Amount of wages earned - Basic
• DA
• Allowances
• Overtime
• Total wages earned
• EPF
• ESIC
• Society
• Income Tax
• Insurance
• Advances
• Recovery of Fine
• Recovery on amount of damages/losses
• Total deductions
• Others
• Net Payment
• Date of Payment
• Receipt by employee/Bank Transaction ID
• Nature of acts and omissions for which fine imposed with date
• Amount of fine imposed
• Damage or loss caused to the employer by neglect or default of the employee
• Signature of Employer/Employer Representative

This page opens the blank statutory form in MedFactory, ready to fill, save and print. See the Form XV reference page for the rule and signatory detail.

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