I think you mean a Non-Contributory Period (NCP) Certificate, which is otherwise referred to as a break-in-service certificate. There seems to be no prescribed format for declaring NCP days, but you can provide the details of the number of days in each year a particular employee was not paid wages and contributions to EP. The attached document is a specimen that you can follow.
From India, Kannur
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EPF Challan - Format.xls
Notice Period Extension Letter Format.doc