Name and address of contractor

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Name and Father's /Husband's Name of the workman

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Nature and location of work

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For the Week / Fortnight /Month ending

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1. No. of days worked

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2. No. of units worked in case of piece - rate

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3. Rate of daily wages / piece -rate

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4. Amounts of overtime wages

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5. Gross wages payable

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6. Deductions , if any

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7. Net amount of wages paid

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