| (a) | Name and                          addresses of the factory or establishment in which the                          unpaid accumulations were earned; | 
                                
                                    | (b) | Wage period                          during which the unpaid accumulations were earned; | 
                                
                                    | (c) | Amount of the                          unpaid accumulations; | 
                                
                                    | (d) | A declaration                          that a list containing the names of employees and the                          amount due to them and paid to the Board has been pasted                          on the notice board of the factory or establishment in                          which the unpaid accumulations were earned. |