I think you mean a Non Contributory Period (NCP) Certificate which is otherwise referred to as break in service certificate. There seems to be no prescribed format for declaring NCP days but you can give the details of number of days in each year a particular employee was not paid wages and contribution to EP. The attached is a specimen that you can follow.
From India, Kannur
4239From India, Kannur
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Expat PF Excluded Employees Contribution & No Due Certificate Clarification.p df