Below Rs.(Rupees...

only)
FORM D
No:

Below Rs.(Rupees...only)
FORM D
No:

Name of Treasury ..

Name of Treasury ..

Computer Seq No:/ Token No:

Computer Seq No:/ Token No:

Date:

Date:

Scroll No: ....................... Voucher No................ .of I / II LOP

Scroll No: ....................... Voucher No................ .of I / II LOP

Deposit chalan no:

Deposit chalan no:

Date:

Amount:

Date:

Amount:

Head of Account:

Head of Account:

Name of work for which land acquired: ...

Name of work for which land acquired: ...

Gazette declaration No:

Serial No in award:

Statement No:

Date:

Gazette declaration No:

Date:

Serial No in award:

Statement No:

Date:

Date:

Name of Payee...

Name of Payee...

I .of

I .of

Village ..Taluk ..

Village ..Taluk ..

Acknowledge the receipt of Rupees .

Acknowledge the receipt of Rupees ..

. On account of cost of land taken by Government as detailed on

..on account of cost of land taken by Government as detailed on

reverse...

reverse...
Signature of payee

Locality..

Signature of payee
Locality..

Pay to .resident

Pay to .resident

...of Village..

...of Village..

station...Taluk..

StationTaluk..

the sum of Rs Rupees

the sum of Rs Rupees

...only)

.only)

Signature, Name & Designation of Land Acquisition Officer

Signature, Name & Designation of Land Acquisition Officer

REVERSE OF FORM D
Details of land, etc., and their values

REVERSE OF FORM D
Details of land, etc., and their values

Locality

Locality

Village .

Village .

Taluk

Taluk

Land .Acres.Cents.

Land .Acres.Cents.

Value Rs

Value Rs

FOR TREASURY USE ONLY

Pay Rs............................. (Rupees ...................................................
.......................................................................only ) in cash / RBR and Rs
(Rupees . Only) by TC
POC NO: ........................................... Date:............./............./..................

Accountant
Received Pay Order Cheque
Signature of Recipient

Treasury Officer
Pay Order Cheque Issued By
Accountant