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00 Total Refund of Advance (5) No.of Days/ Period of non contribution service (if any) Remarks (6) (7) Certified that the difference between the total of the contribution shown under columns 3, 4(a) & 4 (b) of the above table and that arrived at on the total wages shown in column 2 at solely due to rounding off of contributions to the nearest rupee under the rules. a) Date of Leaving Service : b) Reason of Leaving Service : c) Certified that the total amount of contribution (both shares.

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