FORM - I (See Rule 4) Name and Address of the Consumer............................................... Return regarding Water consumed during the month of................................................................................................................. Purpose for which water consumed. Reading at the beginning of the first day of the calendar month under report. Reading at the end of the last day of calendar month under report. Quantity of water consumed in Kilolitres. If the meter was out of order the monthly average consumption of water for previous 3 months of working period. Quantity of water qualifying for rebate according to the assessee. Remarks (*) 1 2 3 4 5 6 7 Industrial cooling spraying in mine pits or boiler feed. (i) from Municipal water supply mains (ii) from well/tube well (iii) from canal (iv) from river (v) from any other source Domestic purpose. (i) from Municipal water supply mains (ii) from well/tube well (iii) from canal (iv) from river (v) from any other source Processing whereby water gets polluted and the pollutants are easily biodegradable. (i) from Municipal water supply mains (ii) from well/tube well (iii) from canal (iv) from river (v) from any other source Processing whereby water gets polluted and the pollutants are not easily biodegradable and are toxic. (i) from Municipal water supply mains (ii) from well/tube well (iii) from canal (iv) from river (v) from any other source (*) for claiming rebate under column 7 the assessee shall indicate in this column the analytical and other reports annexed to this return in support of this claim. Signature of the consumer Name: Designation: Seal:
