OFFICE OF .

Sir,
Sub: Authorisation for drawal of my Pay & Allowances/TA/Leave Salary under the
Note below Para 14.20 of Establishment Manual.
****
I authorise Sri. of .. Section to
receive my pay & allowances/TA/Leave Salary due to me for the month of ...
Please disburse the amount of Rs(Rupees .
. only) as per this authorization and oblige.
Yours faithfully,

SIGNATURE OF THE EMLOYEE

Place :

Name of the Employee :

Section/Party:

Date :
Received payment as authorised
Signature of the Nominee:
Name of the Nominee:
Designation & Section:
Office in which working:

R E C E I PT
Received from the Accountant General (Civil Audit) an amount of Rs
(Rupees . . only)
being the Pay & Allowances/TA/Leave salary due to me for the month of .. 20

Revenue Stamp

Signature:
Name:
Designation:
Section: