G. A. R. 43

[See rule 186(1)]

APPLICATION-CUM-BILL FOR REFUND OF DEPOSIT

Month...................... ....

Bill No...........................

Head of Account..................

Original Challan or Receipt No. & date Bank/Office in which deposited

Name of depositor

Amount Originally deposited
1 2 3 4
     

Rs.

 

 

 

 

Received this ..............................day of..................19..... .the sum of Rupees................being repayable on account of release of deposit described above.

Claimant's Signature................
(with revenue stamp affixed wherever necessary)


Four use in Departmental Office

•I. Received payment of Rs.................. .(Rupees,.....................................) for arranging disbursal to claimants)

* 2. Passed for Payment of Rs........................ .(Rupees........................) to claimants) Shri/Smt......... ............................... ........................against personal deposit account administered by me.

Dated........................

Judge/Magistrate or other officer


For Use in Pay and Accounts Office in case of endorsement 1 above

Passed for payment of Rs...................... .(Rupees...........................).
Payment by cheque No.........................

Pay and Accounts Officer 
Date ........................

* Delete, whichever of endorsements 1 or 2 is inapplicable.