IN THE COURT OF _______

______   Versus   ______

RECEIPT

Received a form “C” for ______/- (______) from this ______ court in the above mentioned case as compensation.

EXECUTANT

Dated: ______ 

______ son of ______ resident of ______, ______

I, personally know ______
son of ______ resident of ______
Who has signed this receipt and has received a
Form “C” for ______/- in my presence. 

Through counsel
______ Advocate, ______