Panchayat:Repo18/Law Manual Page0534

	FORM V
(See Rule 18) Name of the Village Panchayat................... Name of establishment...................................... Half Year:
In the case of deduction from salary In the case of self drawing Officers
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
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
Serial No.PanchayatPanchayatservedRemarks
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
(Signature) (Secretary) Secretary/Verification Officer: Employers/Head of Office