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FORM V
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| (See Rule 18) Name of the Village Panchayat................... Name of establishment...................................... Half Year:
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| In the case of deduction from salary In the case of self drawing Officers
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| Unit/section of employees/labourers Date of deduction from the salaryDate of remittance of amount in thePanchayat, Cheque/D.D. No. If byDate of remittance of amount in theCheque/D.D.No., date. If by cash,No. and date of receipt issued by theDate and details if any other notice is
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| Name and Designationwith Code NumberDemand NumberDemand AmountDate of service of NoticeAmount collectedcash state the particularsDate of collection state the particularsDate of issue of receipt toemployees/labourers
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| Serial No.PanchayatPanchayatservedRemarks
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| 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
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| (Signature) (Secretary) Secretary/Verification Officer: Employers/Head of Office
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