1. Work reference order & date

2. (a) Bill No. & date of Tender :

(b) Amount of Bill :

3. Detailed description of services

4. Period of Services for which payment claim made

5. The rate at which tender/contract/ Supply order was awarded

6. The amount as per approved rate at (5) above which is admissible for payment

7. Tax Component on payment claim Submitted

8. Whether any discrepancy or difference between claimed amount and tendered rate awarded

9. Admissible amount and whether payment can be cleared

10. Relevant Head of Account and budget Provision

In pursuance of record of the information here above Financial Sanction for an amount of (in words) is hereby accorded debitable to detailed Head of Account as provisioned in the approved financial statement (Budget) for F.Y. . It is certified that the said amount is sanctioned post verification of claim and admissibility in consonance of GFR.