FORM

FORM - D		FORM - D
(See sub-rule (1) of rule 3 rule 10)		(See sub-rule (1) of rule 3 rule 10)
Serial No.........................		Serial No.........................
PAY - IN SLIP FOR DEPOSITS		PAY - IN SLIP FOR DEPOSITS
UNDER SENIOR CITIZENS SAVINGS SCHEME, 2004		UNDER SENIOR CITIZENS SAVINGS SCHEME, 2004

Counterfoil (1)		Counterfoil (2)
Depositor's copy		Deposit Office's copy
Name of Deposit Office		Name of Deposit Office
Name of depositor....................................... Address :		Name of depositor....................................... Address :
Father's /Husband's name :		Father's /Husband's name :
*Name of Agent (in case of account introduced through agent) with agency code No., date and validity........... ................................................................................		*Name of Agent (in case of account introduced through agent) with agency code No., date and validity .......... .................................................................
Account No......................Date............................ (to be filled in by deposit office)		Account No.....................Date................................ (to be filled in by deposit office)
Ledger Folio..................(to be filled by deposit office)		Ledger Folio........................(to be filled by deposit office)

Amount of Deposit (Rs.) #		Amount of Deposit (Rs.) #
Cheque/Demand Draft realisation charges (Rs.) ##		Cheque/Demand Draft realisation charges (Rs.) ##
Account Transfer Fee (Rs.) #		Account Transfer Fee (Rs.) #
Fee for issue of Duplicate Pass Book(Rs.) ##		Fee for issue of Duplicate Pass Book (Rs.) ##
Other charges, if any. (Rs.) ##		Other charges, if any. (Rs.) ##
TOTAL AMOUNT (Rs.)		TOTAL AMOUNT (Rs.)
Total amount in words (Rupees.............................................. ..................................)		Total amount in words (Rupees.................................................... ...................................)
Details of CASH DEPOSIT:	AMOUNT	Details of CASH DEPOSIT:	AMOUNT
1000 x		1000 x
500 x		500 x
100 x		100 x
50 x		50 x
20 x		20 x
10 x		10 x
05 x		05 x
02 x		02 x
01 x		01 x
COINS		COINS
TOTAL (CASH):		TOTAL (CASH):
Cheque/Demand Draft No. and date: .......................................................		Cheque/Demand Draft No. and date: .......................................................
Bank / Branch on which drawn: ......................................................		Bank / Branch on which drawn: ......................................................
AMOUNT (RUPEES) :		AMOUNT (RUPEES) :
By (Depositor's signature)		By (Depositor's signature)

Continued from prepage........................		Continued from prepage........................
TO BE COMPLETED BY DEPOSIT OFFICE		TO BE COMPLETED BY DEPOSIT OFFICE
Head of Government Account (to be entered by Deposit Office) # / # #............................................. ................................................................................		Head of Government Account (to be entered by Deposit Office) # / # #............................................. ................................................................................
Received Rs. .................... (Rupees.......................... .................................................................................) as detailed hereinabove. For deposit in Account No............................................ *Agent's Commission at the rate of .......... per cent of deposit amounting to Rs................................ (Rupees........................................................................... ......................................) # # # has been paid at source (under receipt). Cashier's scroll No............................		Received Rs. .........................(Rupees............................... ........................................................................................) as detailed hereinabove. For deposit in Account No............................................... *Agent's Commission at the rate of .................. per cent of deposit amounting to Rs................................ (Rupees........................................................................... ...........................................) # # # has been paid source (under receipt). Cashier's scroll No............................
Signature of Cashier (with name and office seal) Supervisor / Incharge of deposit office alongwith office seal		Signature of Cashier (with name and office seal) Supervisor / Incharge of deposit office alongwith office seal
Note : 1. the cheque / demand draft should be in favour of the Deposit Office, or in favour of the depositor duly endorsed in favour of the deposit office. 2. Cheques / demand drafts are subject to realisation of the proceeds. * score out if not applicable # : In respect of Deposits :- Major Head: 8001 - National Savings Deposits. # # : In respect of various charges :- Major Head 8008 - Income and Expenditure of NSSF.00.104. Other Incomes # # : In respect of agency commission to agents: Major Head : 8008 - Income and Expenditure of NSSF.03.104.		Note : 1. the cheque / demand draft should be in favour of the Deposit Office, or in favour of the depositor duly endorsed in favour of the deposit office. 2. Cheques / demand drafts are subject to realisation of the proceeds. * score out if not applicable # : In respect of Deposits :- Major Head: 8001 - National Savings Deposits. # # : In respect of various charges :- Major Head 8008 - Income and Expenditure of NSSF.00.104. Other Incomes # # : In respect of agency commission to agents: Major Head : 8008 - Income and Expenditure of NSSF.03.104.