^*FORM XIX
   (See Rule 45(2))
   Bill / Cash Memo

                                                                                                                                                Bill No. .............
                                                                                                                                                Dated

Name & Address of the Dealer .................................................................................................................
Registration Certificate No. .....................................................................................................................
Licence No. ............................................................................................................................................
(if any prescribed under any other law)

<sup>_____________________________________________________________________________________________________________
S.No.            Description                Price per                 Qty of                 Total Value                Tax                Total
                     of the goods               Unit                         goods                 of the goods                                     amount
_____________________________________________________________________________________________________________

                                                                                                                                       Total
                                                                                                                                           
                                                                                                                                                    Signature</sup>

^{Certified that in respect of the turnover of the goods mentioned in item(s) of this tax has been paid or / is payable by me or / is payable by Sri / M/s.}

                                                                                                                                                     ^Signature

                          ^{*Ins by G.O.Ms.No. 244 Rev. dt.17.5.1995}