# FORM XVI

##### <span style="color: rgb(34, 87, 122);">**FORM – XVI**</span>  


**(See Section 23 and Rule 25)**

Original

Duplicate Receipts Serial Number

Received from \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ to the credit of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ the amounts detailed below in respect of the Chit Agreement registered under number of \_\_\_\_\_\_\_\_\_\_\_\_\_\_ 200 \_\_\_\_\_\_\_\_.

 Rs. ps.

Payment for current installment

Arrears of subscription (with details)

Penalty for overdue subscription

Fees for inspection of records

Other receipts (to be specified)

 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Total

 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(in words Rupees \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ only)

Date

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for and on behalf of foreman

…………………………………………………………………………………………….............................

Note: Strike out / delete whatever is not applicable. Insert the designation(s) as may be appropriate to the applicant.