FORM C
[See rule 6]
STATEMENT OF DISBTJRSEMENTS
(Section 8 (4) of the Workmen’s Compensation Act, 1923)

Serial No…….. ………. ……… ……….
Depositor…….. ………. ……… ……….
Date ……………………….Rs …………………….
Amount deposited …….. …….. ………
Amount deducted and repaid to the employer under the proviso to Section 8 (1)
.......... ………. ……….. ……….
Funeral expenses paid ……… ……….
Compensation paid to the following dependents :
Name                                                                   Relationship
 ………. ………. ………. ………. ……… ……….
 ……… ……… ………. ………. ………. ……….
 .......... ……… ………. ……… ………. ……….
 Total
 Dated……………………….19………
 Commissioner