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

Counterfoil (1) Counterfoil (2)
Depositors 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)
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
Realization charges (Rs)
Cheque/Demand Draft
Realization charges (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. & date : Cheque/Demand draft No. & date :
Bank/Branch on which drawn :…………………………………. Bank/Branch on which drawn :………………………………….
Amount (Rupees …………………………………………………..) Amount (Rupees …………………………………………………..)
By (Depositors Signataure) By (Depositors Signataure)
(PTO) (PTO)
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 herein above. For deposit in Account No………………
Agent’s commission at the rage of ………percent of deposit
amounting to Rs………… (Rupees……………………….)
has been pai at source (Under receipt).
Cashier’s scroll No…………………….
Signature of Cashier
(with name & office seal)
Supervisor/ Incharge of
Deposit office alongwith office seal
Received Rs…………………………… (Rupees…………………
…………………………………………………………… )
as detailed herein above. For deposit in Account No………………
Agent’s commission at the rage of ………percent of deposit
amounting to Rs………… (Rupees……………………….)
has been pai at source (Under receipt).
Cashier’s scroll No…………………….
Signature of Cashie
(with name & office seal
Supervisor/ Incharge o
Deposit office alongwith office sea
Note :
1. The Cheque / demand draft should be in favour of the
t office, or in favour of the depositor duly endorsed in favour of the
office.
2. Cheques / demand drafts are subject to realisation of the
ds.
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 & 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 & Expenditure of
NSSF.03.104