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SECONDARY SCHEME CLAIM FORMAT

Format No 105
Distributor Name & Address:-VMD Gnanavdivel Vijaya Rajan

Name Of Town :-Pollachi


Period:-01.01.22 To 31.01.22
Name Of T.S.S./TSI:-S.Gnanavasagam

NAME OF PRODUCT :-Special Blend


S.No Name Of Retailer Date Bill No Qty Bill Amt. Discount Claim Amount
%
1 New Uthaman Store 08.01.22 617 18 7949.99 5 397.50

18 7949.99 397.50

Dist. Stamp & Sign. T.S.S. Name & Sign.

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