West Bengal GRS Association

Claim to:

Purpose of application:

Place of Expenditure

Date of Expenditure

Order/Ref No:

Order/Ref Date:

Personal Details

Applicant Full Name

Phone

PAN/GST/TAN ID

Full Address

Details of Expenses/Claim

Description

Quantity

Rate

Amount (Rs)

Total Charges

Service Charge

GST

Other Charge: (Any other charge)

Discount/Deduction:

Grand Total (Rs.) *

Bank Details

Account Holder Name *

Account Number *

IFSC Code: *

Bank Name: *

Branch Name: *

Branch Address: *

Supporting Documents

Upload Bill/ Advice /Claim Application:

Upload Bank Account Details/Cancel Cheque/Bank Statement:

Declaration: The above all information are valid and correct. I have used the above mention expenditure/expenses as per mention specified rate and quantity for said purpose. No such expenditure/expenses were drawn before for the above mention purpose.

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