i ORIGINAL) GOVERNMENT OF KERALA GHALAN Form. R12 Kerala TeasuryGode) | Chalan for Payment of Money into the District Treasury! ‘Sub-Treasury/State Bank of India/State Bank of Travancor GOVERNMENT OF KERALA ‘CHALAN FomT. R. 12 {See ules 102 (6) and 124 of Kerala Treasury Code} Chatan for Payment of Money into the District Treasury! Sub-Treasury/State Bank of india/Stale Bank of Travancore DUPLICATE GOVERNMENT OF KERALA CHALAN 1 Fon. R12 |. {See rules 102) and 124 of Kerala Treasury Go | Chale for Payront of Monay int the District Tr Ssub-Trensun/State Bank of IndiaiState Bank of Tre DO, wit instalment number in purpose coluren GPv. 25/06/2016, 3.00.00 of Kerala Tho soal'stamp of tho Treacury/Bank of Colecton shal ba axed I remittance isin offal capscty ("SDOIDDO), wate carespanding 41. The sealstamp of the TreasuryBank of Colecti sh I a a ' x ee caruersen no ] pte [FT] F cometesen to | pe [TTT] | jemmwerseans [] bas Headotneceamt: [| Heedotaccourt:[ L | Hestotrecunt: | ia Se Hin WS Win SWB Ba GH SOB ia Sty *D00Gode (Dept) | "DDO Code: (Dept) (009) { [ *DD0 Code (Dept) *s00 Code | *spo.code i *800 Code oe sil bert _| eae —— fe By Whompaidand | a os of sy Whom paid and | : 1 By whem paid ana Naps ankles of | roe, | eu Nane and adressefthe| PUPOSESE | Amountin | O¥erto | Name and adress ofthe | FUBDSE | arnGuntin person on whose behalf ». z person on whose behalf | emltancs: | the Bank person on whose behalf] "mMlance & | rmonoyispaie [Sumer any) money paid authority, an ef : | “raney is paid (PaO any Conect Conest | 1 Recaive Recaive | and and | svat gat | receipt feo | | Yeoasury ressuy | | Ofreer | Oficer” | Signature & Designation —— a | ot the. Departmental : Taal |, Qtiearcoutrsneg te To - l somtoeena | stant Recoved &. (Rupeps J] Received & ‘Rupees ony) | Data tonite C Seah) [nated SiaatureofTreasurorCashor —Toasury OficorBank Manager | Signatureof MeasurerCashier Treasury OficerBan Note: | Noto | | | IREVERSE OF FORMT.R, 12 PARTICULARS OF MONEY PAID REVERSE OF FORM T.R. 12 PARTICULARS OF MONEY PAID REVERSE OF FORMT.R. 12 PARTICULARS OF MONEY PAID Currency Notes | No. Amount in’ | Ps. Currency Notes | No. _Amountin® | Ps. Currency Notes | No. Amount in z 1000 | dt 1000 1000 z so | | =, 600 [= 500 = 100 z= 100 = 100 Foe 50 x50 [eee rea «20 = 20 [= 2 : ican 210 z 10 Poros | icici = 6 z 2 z 2 - a4 ean eon © 4 Total Notes Total Notes Total Notes Coins Coins Coins __ 10 se z to | ‘10 I os | its, : c 5 a eg fue, m2 ie ia, | 1 = zo z ees ae Ps 50 | Ps Total Coins Tolat Coins Total Coins a { { | Grand Total Grand Total Grand Total ania ett a pee ee