Zone

: _________________

Name of DM : _________________

CREDIT CLAIM FOR SPECIAL DISCOUNT

Franchise : __________
Name of Distributor : M/s. ________________________________________________________________________

Claim No.

City :

Date :

State :
As per Distributor Bill

Sr.
No.

Name of Institution /
Hospital

City

(A)

(B)

(C)

Distributor Bill
No.
(D)

Distributor
Bill Date

Product Name
(E)

Qty
(F)

: _____________

tract no (
Discount
STD PTD
Discount
to be
%
Special Discount
J&J
J&J
filled in
(Rate as
Rate
approve
Value Claimed
Invoice No. Invoice Date by DM
per J&J
approved as
d as per
Rs.
while
Invoice. )
per PPS
PPS
Verificati
(G)
(H)
(I)=(G) X (H)
(J)=(F)X(I)

Total
Supportings/ attachments required with claim :
1) Copy of supply order from Institution / Hospital (PO)
2) Copy of duly acknowledged and stamped Delivery challan by Inst/ Hospital
3) Copy of Distributor Bill duly stamped and signed
4) Copy or J & J Invoice number on Distributor
5) Copy or number of approved PPS/Contract

Distributor Stamp & Signature

Verfied By
Regional Sales Head (DM & ASM/RSE/RSM)

Declaration : I/We hereby declare that above claim has not been claimed before