¾ø¨º

ë à ¨Î ¼ú¾ Ìè´ 30 ¼ú¾¨à ¡æºëκ ¼û ïª—Æ ÆêºÆ

ë . 29 Éæ¾ø ïÀåó ¡å¨îºø ÀºòÆ
General 29
Payable within 30 days from the date of issue. (A4* S., & E.) 5/57
(Internet Version)
¡åÀÌê ïªÉ¾ ª¸¾Æ, ¡Æ ÊûÚËÆ
Refund Account, Head

¡å¼åÆïÄ¾à ¡åÀÌê ïªÑÄ Ì¿Íå ¢¼èÖÀºà ï¨ïǾ ¢ÈàõŠ ÀºòÆ

APPLICATION FOR REFUND FROM REVENUE

ïªÉ¾ê Ⱦà¾åïªà ¾Ä
Name of Payee

¡åÀÌê ïªÑÄ ÀèÎè¿ —ÌàºÇ Íå ¦à Ì¿Íå ïÄÄ ¢ÈàõŠÀºòÆ ¢¼úÖÀºà

¨ø×Ä´ ïÍàºë Éì ̊ÀìÚ¸ ¨Çæ¸ê
Details of refund with full reasons for the application

¡åÀÌê ïª—Æ ÆêºëÉ ¡æºø Äê¼È (¡¨ëÖ¾à Íå ¢È¨à¨ïľà ̴;à Çæ.

¨Î ÆêºëÆú) Rs.
Amount to be refunded (To be stated in words and figures)

Äê¼È ª¸¾´ ¦¨ºë ¨Î ¼ú¾Æ Íå Ìà»å¾Æ ¼ ¦ïÌà ¦¨ºë ¨Ç¾ê ÈæÂì

¡Æ ÊûÚËÆ Íå ¡¾ê ÊûÚËƼ ïÄÍú ¼æ¨à—Æ ÆêºëÆ. (¢¼è¾à ïÄÄ Äê¼È
—ÊåÈ Äê¼È¨´ ¡æºëÎºà ¨Ç¾ ȼàï¼à ¾Š ¦ïÌà ¦¨ºë ¨Ç¾ ȼ ¦Ä
—ÊåÈ Äê¼È ¼ Ì¿Í¾à ¨Î ÆêºëÆú)
Date and place of credit and Head, Sub-head and Items of Revenue to
which the amount was credited. (If the sum was included in a larger
amount, such larger amount should be stated)

Ìͺø¨Æ
Certificate
Äê¼Èà ¡åÀÌê ïªÑÄ´ ïÍàºë ÉÊïƾà ïÄÍú ¼æ¨àÉê¸ê ¨Çæ¸ê ¾øÉæǼú
Âɺà, ¦ïÌà ¡åÀÌê ïª—Æ Æêºë Äê¼Èà ¢Íºø¾à ̿;à É ¡æºø ÀÖ¼ú ¡å¼åƊ
ª¸¾´ ¦¨ºë ¨Ç¾ ȼ Âɺà, ¦Ä Äê¼È ¨Èè¾à ÉïǨ ÈÂå 諭 ¾æºø
Âɺà ÄÄ ïÄÆú¾à Ìͺø¨ ¨Ç•.
I hereby certify that the reasons given for making the refund are
correct and that the sum to be refunded was credited to revenue as
indicated above and the sum was not drawn previously.
* ¨ƒïƒÖïƾà ÈÂå ª¾à¾å ȼ ¡Æ Ìͺø¨Æ ¼ ïŠ ÌÄ­ ¡Äê¸å ¡æº.
* ïÆåàªñ ï¾åïŒ ¾Š ¨Àå ÍÎ ÆêºëÆú.
* A certificate of credit from the Kachcheri is attached.
* To be ruled off if not applicable.

........................................................
¢ÈàÈéÄ ¨Ç¾ ï¼Àåںàºë Àò½å¾øÆå.
Head of Department making the Application.

¼ú¾Æ
Date
Ãå¸à¶åªåÇïƾà Ⱥà ÂÈÆ
Treasury Authority

H - 022255 (2004/09) Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåںàºëÉ