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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:___________________________________
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S.
No.
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PRODUCT
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SALES
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CONCESSION
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Name of Institutional Agency with name & address / private trader with name and address of the dealer
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Qty. sold
(MT)
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Preceding months Sales Returned*
(MT)
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Net qty. sold
(MT) (4-5)
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Rate of concession
(Rs./PMT)
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Amount
Claimed
(Rs)
(6x7)
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(1)
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(2)
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(3)
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(4)
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(5)
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(6)
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(7)
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(8)
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1.
2.
3.
4.
5.
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IMPORTED
DAP
MOP
iNDIGENOUS
DAP
COMPLEXES
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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