Receipt of Prize money Received from the Directorate of State Lotteries/DLO, a sum of Rs..../(Rupees.........................) after deducting - % Agents prize and - % sellers Bonus Rs..../- (Rupees............) And 1. Tax @ - % surcharge @ - % on income tax Rs..../- (Rupees....... ............) from the prize aount of Rs...../- (Rupees...... ..............) due to me against....... Prize winning ticket No......of ......... draws of Kerala State Lotteries which held on...... Place: (Sd/- on revenue stamp) Date: (without amount Exceeds Rs.500/-) Name and Address.
