1. Name

2. Sex

3. Father’s/Husband’s Name

4.Serial Number in the Register of
    adult/child worker

5. Department

6. Designation

7. Date of joining employment

8. Date of  discharge/dismissal/
   quitting employment/ Superannuation
    death while in service

9. Date of payment in lieu of leave
   with wages due in such cases

10. Whether leave in accordance with scheme under scheme 79(8) was refused

Calendar year of service (i.e.
Previous year)

Leave due as on Ist January of the year in column 1

Leave availed during the year

Leave refused
out of regular
leave mentioned
in column 3

Refused

Regular

Refused

Regular

Dates

From

To

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

Number of working days for computation of
leave during the year mentioned in Column 1

Regular leave
earned for the year
mentioned in Col.1

Balance on leave admissible
on Ist January of the year  following the year mentioned in Col. 1

Days worked

Lay off

Materinity leave
up to 12 weeks

Leave with wages
enjoyed

Total
(9 to 12)

Refused

Regular

(Col. 2+8-4)

Col. 3+14-5-8

(9)

(10)

(11)

(12)

(13)

(14)

(15)

(16)

Leave period (i.e.
Col. 4+Col.5 in

Days

Details of wages paid

Total wages paid for the period of leave with wages enjoyed (Rs.) (Col.17xCol.20)

Signature

Normal rates of wages excluding of any overtime
as well as bonus but including of Dearness Allowance (Rs.)

Cash equivalent of the advantages occurring through the concessional
sale of foodgrains
and other articles

Rate of wages for leavewith wages
paid (Rs.) (Col. 18+Col.19)

(17)

(18)

(19)

(20)

(21)

(22)