# FORM XXI ##### **FORM – XXI** **(See Rule 28(2))** **Name of the Foreman**

i) Office where the bye-laws of the chit and year of the bye-laws of the chit.	(i) Registration No.
ii) Date of which the balance sheet was prepared.	(ii) Name of the Foreman
iii) No. of instalments conducted till date of balance sheet	(iii) Chit amounts
	(iv) No. of instalments

**I – RECEIPTS AND EXPENDITURE**

Receipt	Current Year	Total including previous years	Expenditure	Current year	Total including previous years
1	2 Rs	3 Rs	4	5 Rs	6 Rs

1. Subscription paid by the prized and non-prized subscribers.	1. Prize amounts disbursed to prized subscribers.
2. Receipts under dividend	2. Interest paid to subscribers
3. Interest realized from the subscribers	3. Amounts paid to defaulter non-prized
4. Contributions by substituted of assignee non-prized subscribers, in respect of dues of defaulters.	4. Amount contributed by foreman for payment of the prize amount.
5. Any other amount received from subscribers.	5. Foreman’s commission.
6. Amount contributed by the foreman for payment of prize amount.	6. Amounts on account of interest realized for delayed payments and forfeited dividend.
7. Interest accrued from investments	7. Dividend paid
8. Other items (details to be annexed)	8. Sinking fund
9. Investments withdrawn	9. Other items (details to be annexed)
	10. Investments made
Grand Total :	Grand Total :

**II - STATEMENT OF ASSETS AND LIABILITIES**

S.No	Assets	Rs	Ps	Liabilities	Rs	Ps
1	Amounts due on account of arrears of subscription due from prized subscribers.			1. Amounts paid by non-prized subscribers (including dividends)
2	Amounts due from the subscribers including the subscriptions			2. Amounts due to non-prized defaulter subscribers
3	Interest due from defaulter subscribers			3. Arrears of prize amount due to prized subscribers
4	Investments in Bank (including interest thereon)			4. Arrears of prize amount due to prized subscribers
5	Other items (details to be annexed)			5. Other items (details to be annexed)
6	Sinking fund			6. Sinking fund
	Total			Total

**III - DETAILS OF INVESTMENTS**

S.No		Rs.	Ps.
1	Investment made on account of the failure on the part of prized subscribers to receive the prized amount due to them
2	Investment made on account of lumpsum collection made from defaulter prized subscriber
3	Amount deposited for payment to nonprized defaulter subscribers
4	Investments on account of other items of receipts of the chit (details to be annexed)
	Total

**IV – ASSESSMENT OF VALUE OF INVESTMENT** 1. Investment in Pass book account number. 2. \* Amount due from the future instalments of the chit as per bonds, etc., obtained for instalments of the chit including the arrears of Rs. due on account of defaulting instalments from defaulters. 3. Balance of contributions due from the foreman on account of prize amount received by him. Note : To facilitate audit of balance sheets, the following statements of details should be annexed by the foreman to the balance sheet. i) Statement of details of receipts and expenditure for each instalments. ii) Of disbursement. iii) Of the prize amount in respect of each instalment and iv) Statement of details of arrears due on the date of the preparation of the balance sheet from the prized and non-prized subscribers. \--------------------------------------------------------------------------------------------------------------------------------- \* Particulars of documents to be entered here. Security offered by the foreman, hypothecation bonds, etc., executed under Section 20, and hypothecation bonds etc., obtained from the prized subscribers under Section 31 of the Act. **V – CERTIFICATE BY FOREMAN** I certify that the above accounts have been prepared correctly and that they contain a true and complete statement of the affairs of the chit. Date : Name and Signature of foreman **VI – CERTIFICATE BY AUDITOR** Certified that I have examined the chit books and records maintained in respect of the chit \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ the byelaws of which have been registered in \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ as number \_\_ 200\_\_ conducted by foreman \_\_\_\_\_\_\_\_\_\_\_\_ and have verified the entries in the accounts with the books. The accounts are drawn up in conformity with the provisions of the Chit Funds Act, 1982 and the Rules framed thereunder. Date : Name and Signature of the Auditor