Receipt Number :1589791 FORM No. O.T.C.

5 Date:13-10-2023

(See Subsidiary Rule 43)

RECEIPT FORM
OFFICE OF THE REGISTERING OFFICER
UNDERTHEBUILDING&OTHERCONSTRUCTIONWORKERS'
(R.E.& C.S) ACT, 1996-CUM-DISTRICT LABOUR OFFICER

Received From : PRABAL JYOTI MOHAPATRA

Father's name/Spouse's name :CHINMAYA MOHAPATRA

Present Address :PUTINA,PUTINA,BALASORE

Permanent Address :PUTINA,PUTINA, BALASORE,

With reference to the Beneficiary Registration No. : ODBLS001178914 Date: 31-12-2021 the sum
of Rs.50.0 on account of Annual contribution for the year 2023, instalment(s) of Annual contribution
of beneficiary under Section 16 of the Building & other Construction Worker (R.E.& C.S) Act, 1996
and Rule 267 Rule 267 of Orissa Building & other Construction Workers (R.E. &C.S.) Rule, 2002

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