West Bengal Fonn No.

1077 L&LR N
SB P· • 07.9-09·7 8
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 Form-4
[See Rules 8 J~ and 31 (2)]
Receipt No.- C 10210619 / 0
4. lS SArrBANKUBA GRAI~ PANCHAYAT
Receipts for Tax, Rates and Fees as .assessed by Gram Panchayat l ') o. e-n
(Duplicate to be made out by both sides Carbon paper process) ·, J .:>,
1. Name and address of assessee : t.,- fl o ,
1 /J-.· •- /'1_ J .Holding Ho~ (If any)
"Ql..l _\ ' K.-. 0, IT) V). rJ CJ Y\..,/
:· Am~receivedonaccou ntof: 8/~ ~012--2.3 ~"/-
Rs .....................!'"...... .
~ a x on land and b~lding for the period (quarter ................. (Year)
(b) Fees on registration of vehicles for the period................................. Rs .............................
(c) Fees for sanitary arranged for the period.......................................... Rs .............................
(d) Water rate for the period.................................................. ............... . Rs . ........................... .
·"
(e) Light rate for the period.............................................. .................... . Rs . ........................... .
(f) Conservancy rate for the period...............................\\ ................... Rs . ........................... .
(g) Fees on trade registration certificate for the period......\ ................. . Rs. ............................
(h) Tolls on person, vehicles, animals or ferry established by or under
the management of Gram Panchayat for the period......................•.. . Rs . ..... •.• .................... .
(i) Fees for the use of burning ghat Rs . ........................... .
G) Fees for rigs of shallow or deep tubewells for the period.............. . Rs . ............................ .
(k) Fees on village produces sold in village markets Rs . ........................... .
(I) Fees on erection, exhibition; Fixing any advenisement for public·
display for the period....................................................................... Rs. . e. e f .t

(m) Penalty under by-law in terms of Sec.-47 ·-._ Rs . ........................... .

d , • -~-/\ ~- · Rs . .. •.• ........................ .
"4i, ·,': _~
(n) Others .
.t) O • /2
;_-*, )f~
ld-1' . • rrr7l / ·_

/"10.b!/4•• 2-- • K_j • Totai:. Rs. ...?...'::.. ~l..:......_.

Dated..........l........ .... ........... "JI • •• . . " • • --

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.-. .. '•l.. \; • \,. •• ~ -
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the........................... ....20

. .
Note: (1) No member of the Panchayat shall be entrusted with this job. (Signature with date)
(2) If any payment Is made by cheque or draft, Its number and Secretary /Tax Collefj'; ofGram Panchayat
date shall be noted against the amount. TaxCo ctor
 Re£ No. ...........................
f9./.!./.-fff.
Dat e ...

This is to Certify that Sri I Smt......

.. . /4;_:... 17-~.... ~,. ,L) (·; ···
S~, .......L.~~..J....1-'L........... .~6 .:.. . 4/.fl.i,............
......
..............,
of -lillllPe. .......... .7./.. .. . •.........................•....... , P.
0. ... .. ... 0. ..

dent of Sat ban kur a Gra m Panchayat

Dist.-Paschim Medinipur is a perm ane nt resi
under Garhbeta-III Pan cha yat Samity.

• me?er 11}!!_!'-th is• approxu•nately Rs........... .................... .

Hi°is IRer flamz·1ry inco
•••••••••••.•......................................................) only.
He/ She is '/aiown to me.
(Rs••••••••••
. C. Community................................... .
He I She belongs to Scheduled Caste I Tribe I O.B
His/Hier sub-caste zs• ........................................-............. .
character.
So far as I know he I she bears a good moral
I wish him I her all success in life.
Certificate ends. ...
.
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Satbankur, G ijan
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ulllL .1,9 y:-- t ,-:- . .:
. . ~rn,ry
• 4ou Satbankura Gram Panchayat
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