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PROFORMA 'C'
Pre receipted claim for "on account" payment
(To be submitted in duplicate separately for imported
& indigenous fertilizers together with proforma
A, E/F & G)
Authority No. Ministry of Chemicals & Fertilizers
Bill No._______________
(Department of Fertilizers) letter Date _______________
No._______________ dated______
State / UT ____________
Month to which relates__________
Name of the Claimant with full address_______________
Details of the Claim
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S.
No.
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Product
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Net
quantity sold as per col. 6 of the Proforma A
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Rate of Concession
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Amount of
Concession
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80%
of the
amount now claimed
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(MT)
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(Rs./PMT)
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(Rs.)
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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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1.
2.
3.
4.
5.
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IMP.
DAP
MOP
iNDIG.
DAP
COMPLEXES
SSP
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Total
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Total amount claimed being rounded
off Rs._________ (Rupees___________________)
1. Certified that the quantity shown in the column 6
of the proforma 'A' on which concession is being claimed
is on net weight basis and does not include the weight
of bags. It is further certified that this quantity
of fertilizers has been sold on net weight basis and
exclusively for agriculture use and not for industrial
or any other use.
2. Certified that all the conditions prescribed in the
Ministry of Chemicals & Fertilizers (Department
of Fertilizers) letter No.____________________ dated
______________ have been fulfilled.
Signature of the claimant
(With name, date, designation & Stamp)
Received Rs._____________(Rupees_____________________________________)
Revenue Stamp
Signature of the claimant
(With name, date, designation & Stamp)
Please pay by crediting our current/CC Account No.____
with State Bank of Patiala, Shastri Bhawan, New Delhi.
Signature of the claimant
(With name, date, designation & Stamp)
To
ED, FICC, 8th Floor, Sewa Bhawan, R K Puram, New Delhi.
/
Director of Account, Department of Fertilizers, 4th
Floor Super Bazar, Connaught Circus, New Delhi.
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