TO BE FILLED IN BY THE REMITTER

To be filled in by the Department officer of the Treasury

By whom tendered

Name (or designation) & address of the person on whose behalf money is paid

Full particulars of the remittance and of authority (if any)

Amount

Head of Account

Order to the Bank

Rs.

Ps.

Date
Correct Receive and grant receipt

(Signature and full designation of the officer ordering the money to be paid in)

Signature

Total:-

(in words) Rupees.

To be used only in the case remittance to the Bank through

Department Officer,

Treasury Officer

Received payment (in words) Rupees

Treasurer

Accountant

        Date

Treasury Officer