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PROFORMA
'A'
(To be submitted in triplicate)
To
The Director of Agriculture
1. Name of the claimant with full
address:_____________________________________
2. Month for which the claim is
submitted:___________________________________
| S.No. |
PRODUCT |
SALES
|
CONCESSION
|
| Name of Institutional
Agency with name & address / private trader
with name and address of the dealer |
Qty.
sold (MT) |
Preceding
months Sales Returned* (MT) |
Net
Qty. sold
(MT)
(4-5) |
Rate
of concession (Rs./MT) |
Amount
Claimed (Rs)
(6x7) |
| (1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
| 1 |
IMPORTED DAP |
|
|
|
|
|
|
| 2 |
MOP |
|
|
|
|
|
|
| 3 |
INDIGENOUS
DAP |
|
|
|
|
|
|
| 4 |
COMPLEXES |
|
|
|
|
|
|
| 5 |
SSP |
|
|
|
|
|
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Certified that the above details
are true and fertilizer conforms to prescribed quality
as per Fertiliser Control Order specifications.
For (NAME OF THE MANUFACTURER
/ IMPORTER)
Company authorised signatory
(Name, Designation with seal)
It is certified that the quantity
as shown in the proforma has been verified from the
sales invoice/sales day books maintained by the company.
For (Statutory Auditors)
Authorised signatory
(Name, Membership No. with seal)
Place:_____________________
Date:______________________
CC:
1. ED, FICC, Department of Fertilizers, 8th Floor,
Sewa Bhawan, R. K. Puram, New Delhi-110066. For indigenous
fertilizers/ SSP
2.
Director of Accounts, Ministry of Chemicals &
Fertilizers, Department of Fertilizers 4th Floor,
Super Bazar Building, Connaught Place, NEW DELHI.
For imported fertilizers.
*
Quantity sold and concession received during the preceding
months of______ and returned back during current month.
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