Below Rs..(Rupees..

only)

FORM No. A
[ Vide G.O. (P) 405/77/Fin dated 19-10-1977]

Bill for withdrawal of amounts under the Family Benifit Scheme for Government Employees
Name of Treasury ...............................................................................................................................................................
FOR TREASURY USE
Computer Sequence No:\Token No:
Scroll No: ...........................................
DDO Code : (Dept)

(DDO)

Date :

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

Designation : ..........................................................................................................

Name of Office :...................................................................................................................................................................

Bill No : ................................................................................
Head of Account:

Details of Government Employee

Name: ..
Designation : ...............................................................................................................................................................
Name of office (last served) :......................................................................................................................................
Date of option to Scheme:
Date of retirement/relief/death:
/
/
/
/
Designation (at time of option) ..................................................................................................................................
Name of office (at time of option) .............................................................................................................................
Rate of contribution : Rs ...............
Sl Name &
Whether
No & date of
Amount in Rs
Remarks
No address of the employee/
order of
Subscription Government Gross payment If part payment
person (s)
nominee/heir & sanction and
from the
contribution
reason, partly
to whom
share to which the authority
party
paid earlier,
payable
he/she is
who sanctioned
details
entitled
1
2
3
4
5
6
7
8

Total
Rs ................................................
Deduct recoveries Rs:............................ Details :.....................................................................................................
Net amount
Rs: .............................(Rupees.............................................................................................only)
Received the above detailed amount.
Signature Name &Designation of Drawing Officer
FOR TREASURY USE ONLY
Pay Rs...................... (Rupees .......................................................................................................................only) in CASH, Rs...........................
(Rupees................................................................... .................................................only) by 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

CERTIFICATE

Certified that amount claimed in the bill has not been drawn previously and the details
furnished above are correct as the account available in the office and the necessary noting in the
concerned registers.
Place:
Date:

Signature, Name & Designation of Drawing Officer.

SPACE FOR ENDORSEMENT

Contents Received,
Signature of the Drawing Officer
Please pay the amount to Sri/Smt ................................................................................................
Whose signature is attested below.
Signature of the messenger
Contents Received
Signature of the Drawing Officer
Signature of the messenger
Note:

Copy of sanction order to be attached to this bill.