Odisha Building & Other Construction Workers'

Welfare Board, Government Of Odisha.

Receipt Number : 1665155 FORM No. O.T.C. 5 Date : 02-11-2023

(See Subsidiary Rule 43)

RECEIPT FORM
OFFICE OF THE REGISTERING OFFICER
UNDER THE BUILDING & OTHER CONSTRUCTION WORKERS'
(R.E.& C.S) ACT, 1996-CUM-DISTRICT LABOUR OFFICER

Received From : SRIKANTA JENA

Father's name/Spouse's name :

Present Address : PATAGAN JHINKIRIA, District: BALASORE,

Block: BALASORE, Grama Panchayat:
OLANDA SARGAN,

Permanent Address : PATAGAON JHINKIRA, State: ODISHA,

District: BALASORE, Grama Panchayat:
OLANDA SARGAN,

with letter/application 1665155 Date 02-11-2023 the sum of 50.0 (Rupees fifty only) of renewal
fees of beneficiary under Section 12 of the Building & other (R.E. & C.S) Act. 1996 and Rule
265(2) (iv) of Orissa Building Construction Workers' Welfare Cess Rules.

Note:
(i) This is an electronically generated receipt from the system, which doesn't require signature.