Name _______________________________ Security Rs. ______________________
House No. ___________________________ Balance for Rs. ____________________
Sector _______________________________
Application No. _______________________ dated ____________________________
Receipt No. __________________________ dated ____________________________
To
The cashier,
Please pay to Shri _______________________
On account of refund of security.
Prepared by: -
Checked by: -
Witness by: -
Name _______________________________
House No. ___________________________ Sec. _____________
Account No. __________________________
Signature of payee
1. Certified that all the above relevant entries have been cancelled, account
closed and nothing is due.
S.D.O.
2. Certified that the original receipt of security has been misplaced by me.
If it will be traced out at a later stage I will prefer no claim.
Signature of payee
3. Certified that the hand receipt has been audited by the I/A.
4. Certified that the final bill has been audited by the RA.