OFFICIAL The World Bank W. (202) 473-1000 INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D. .20433 Cable Address: INTBAFRAD INTERNATIONAL DEVELOPMENT ASSOCIATION vR * Cable Address: INDEVAS It'l6 V4,, .2%2012 Mr. S. G. Dastidar Controller of Aid Accounts and Audit Department of Economic Affairs, Ministry of Finance 5th Floor. 'B' Wing Janpath 3hawan, Janpath New Delhi, India 110 001 Dear Sir. Re: IDA Financing 5161-IN (Karnataka Health System Development and Reform Project. Additional Financing.) Additional Instructions: Disbursement I refer to the Financing Agreement between India (the "Recipient") and the International Development Association (the "Association") for the above-referenced project, dated .. I(Il!) The Agreement provides that the Association may issue additional instructions regarding the whd raw.al of the proceeds of financing 5161-IN ("Finarcing"). This letter ("Disbursement Letter"), as revised from time to -ime, constitutes the additional instructions. The attached World Bank Dislursement Guidelines for Projects, dated May 1, 2006, ("Disbursement Guidelines") (Attachment 1), are an integral part of the Disbursement Letter. The manner in which the provisions in the Disbursement Guidelines apply to the Financing is specified below. Sections and subsections in parentheses below refer to the relevant sections and subsections in the Disbursement Guidelines and, unless otherwise defined in this letter, the capitalized terms used have the meanings ascribed to them in the Disbursement Guidelines. I. Disbursement Arrangements (i)Disbursement Methods (section 2). The following Disbursement Methods may be used under the Financing: * Reimbursement (ii) Disbursement Deadline Date (subsection 3.7). The Disbursement Deadline Date is 4 months after the Closiing Date specified in the Financing Agreement. Any changes to this date will be notified by the Association. II. Withdrawal of Financing Proceeds (i) Authorized Signatures (subsection 3.). An authorized signatory letter in the Form attached (Attachment 2) should be furnished to the Association at the address indicated below providing the narie(s) and specimen signature(s) of the official(s) authorized to sign Applications: 1 The World Bank P.O. Box 416 New Delhi 110 001, India Attention: Mr. Onno Ruhl Country Director, India (ii) Applications (subsections 3.2 - 3.3). Please provide completed and signed (a) applications for withdrawal, together with supporting documents and (b) applications for special commitments, together with a copy of the commercial bank letter of credit, to the address indicated below: The World Bank No. 11, Taramani Main Road Taramani, Chennai - 600 113 India Attention: Ms. Samvita R. Aritkatla, Finance Officer (iii) Electronic Delivery (subsection 3.4) The Association may permit the Recipient to electronically deliver to the Association Applications (with supporting documents) through the Association's Client Connection, web-based portal. The option to deliver Applications to the Association by electronic means may be effected if: (a) the Recipient has designated in writing, pursuant to the terms of subparagraph (i) of this Section, its officials who are authorized to sign and deliver Applications and to receive secure identification devices ("Tokens") from the Association for the purpose of delivering such Applications by electronic means; and (b) all such officials designated by the Recipient have registered as users of Client Connection. If the Association agrees, the Association will provide the Recipient with Tokens for the designated officials. Following which, the designated officials may deliver Applications electronically by completing Form 2380, which is accessible through Client Connection (https://clientconnection.worldbank.org). The Recipient may continue to exercise the option of preparing and delivering Applications in paper form. The Association reserves the right and may, in its sole discretion, temporarily or permanently disallow the electronic delivery of Applications by the Recipient. (iv) Terms and Conditions of Use of Tokens to Process Applications. By designating officials to accept Tokens and by choosing to deliver the Applications electronically, the Recipient confirms through the authorized signatory letter its agreement to: (a) abide by the Terms and Conditions of Use of Secure Identification Devices in connection with Use of Electronic Means to Process Applications and Supporting Documentation ("Terms and Conditions of Use of Tokens") provided in Attachment 3; and (b) to deliver the Terms and Conditions of Use of Tokens to each such official and to cause such official to abide by those terms and conditions. (v) Advances (sections 5 and 6). The advancing of Credit proceeds into a designated account is not a Disbursement Method currently available under this Credit. As such, applications only in support of the Disbursement Methods listed in subsection I (i) of this letter may be sent. III. Reporting on Use of Financing Proceeds (i) Supporting Documentation (section 4). Supporting documentation should be provided with each application for withdrawal as set out below: 2 * Reimbursement o Interim Unaudited Financial Report (IUFR), in the form attached (Attachment 4), for reimbursement applications submitted on quarterly basis; IV. Other Important Information For additional information on disbursement arrangements, please refer to the Disbursement Handbook available on the Association's public website at https://www.worldbank.org and its secure website "Client Connection" at https://clientconnection.worldbank.org. Print copies are available upon request. If you have not already done so, the Association recommends that you register as a user of the Client Connection website (https://clientconnection.worldbank.org). From this website you will be able to prepare and deliver Applications, mon'tor the near real-time status of the Financing, and retrieve related policy, financial, and procurement information. All Recipient officials authorized to sign and deliver Applications by electronic means ar- required to register with Client Connection before electronic delivery can be effected. For more information about the website and registration arrangements, please contact the Association by email at . If you have any queries in relation to the above, please contact Mr. Junxue Chu Senior Finance Officer at service account email address CTRLN-Chennai@worldbank.org using the above reference. Yours sincerely, Authorized Signatory South Asia Region Attachments 1. World Bank Disbursement Guidelines fgr Projects, dated May 1, 2006 2. Fori for Authorized Signatures 3. Terms and Conditions of Use of Secure Identification Devices in connection with Use ofElectronic Means to Process Applications and Supporting Documentation, dated January 20, 2010 4. Form of "Interim Financial Report" 3 Cleared with and cc: Juan Carlos Alvarez (LEGES) Patrick M. Mullen (SASHN) Cc with copies: Mr. M. Madan Gopal, Secretary, Department of Health and Family Welfare, Govt. of Karnataka, Bangalore Mr. Vishal R., Project Administrator, KHSDRP, Govt. of Karnataka, Bangalore Mr. L.V. Nagarajan, Principal Secretary. Finance Department, Govt. of Karnataka, Bangalore Mr. Mukesh Nandan Prasad, Executive Director, India Mr. Manoj Pant, Senior Advisor to Executive Director for India 4 THE WORLD BANK DISBURSEMEtT GUIDELINES FOR PROJECTS MAY 2006  Attachment 2 Form of Authorized Signatory Letter Controller of Aid Accounts and Audit Department of Economic Affairs, Ministry of Finance New Delhi, India 110 001 [DATE] The World Bank P.O. Box 416 New Delhi 110 001, India Attention: Mr. Onno Ruhl Country Director Re: Financing No. 5161-IN I refer to the Financing Agreement ("Agreement") between India (the "Recipient") and the International Development Association (the "Association"), dated , providing the above Financing. For the purposes of Section 2.03, of the General Conditions as defined in the Agreement, any '[one] of the persons whose authenticated specimen signatures appear below is authorized on behalf of the Recipient to sign applications for withdrawal and applications for a special commitment under this Financing. For the purpose of delivering Appli:ations to the Association, 2[each] of the persons whose authenticated specimen signatures appears below is authorized on behalf of the Recipient, acting 3[individually] 4 ointly], to deliver Applications, and evidence in support thereof on the terms and conditicns specified by the Association. 5[This confirms that the Recipient is authorizing such persons to accept Tokens and to deliver the Applications and supporting documents to the Association by electronic means. In full recognition that the Association shall rely upon such representations and warranties, including without limitation, the representations and warranties contained in the Terms and Conditions of Use of Secure Identification Devices in connection with Use of Electron,c Means to Process Applications and Supporting Instruction to the Recipient: Stipulate if more than one person needs to sign Applications, and how many or which positions, and if any thresholds apply. Please delete this footnote in final letter that is sent to the Association. 2 Instruction to the Recipient: Stipulate if more than one person needs to jointly sign Applications, if so, please indicate tie actual number. Please delete this fogtnote in final letter that is sent to the Association. Instruction to the Recipient: Use this bracket if any one of the authorized persons may sign; if this is not applicable, please delete. Please delete this foo:note in final letter that is sent to the Association. 4 Instruction to the Recipient: Use this bracket only if several individuals must jointly sign each Application; if this is not applicable, please delete. Please delete this footnote in final letter that is sent to the Association. ' Instruc:ion to the Recipient: Add this paragraph if the Recipient wishes to authorize the listed persons to accept Tokens and to deliver Applications by electroniz means; if this is not applicable, please delete the paragraph. Please delete this footnote in final letter that is sent to he Association. 5 Documentation ("Terms and Conditions of Use of Tokens"), the Recipient represents and warrants to the Association that it will deliver to each such person a copy of the Terms and Conditions of Use of Tokens and will cause such persons to abide by those terms and conditions.] This Authorization replaces and supersedes any Authorization currently in the Association records with respect to this Agreement. [Name], [position] Specimen Signature: [Name], [position] Specimen Signature: [Name], [position] Specimen Signature: Yours truly, /signed / [Position] 6 Attachment 3 Terms and Condition of Use of Secure Identification Devices in connectioin with Use of Electronic Means to P1rocess Applications and Supporting Documentation January 20, 2010 The World Bank (Bank)' will provide secure identification devices (Tokens) to permit the Borrower2 to deliver applications for withdrawal and app: ications for special commitments under the Agreement(s) and supporting documentation (such applications and supporting documentation together referred to in these Terms and Conditions of Use as Applications) to the Bank electronically, on the terms and conditions of use specified herein. A. Identification of Users. 1. The Borrower will be required to identify in a completed Authorized Signatory Letter (ASL) duly delivered to and received by the Barik each person who will be authorized to deliver Applications. The Bank will provide Tokens to ez.ch person identified in the ASL (Signatory), as provided below. The Borrower shall also im nediately notify the Bank if a Signatory is no longer authorized by the Borrower to act a3 a Signatory. 2. Each Signatory must register as a uer on the Bank's Client Connection (CC) website (https://clientconnection.worldbank.ors) prior to delivery of Tokens. Registration on CC will require that the Signatory establish a CC password (CC Password). The Signatory shall not reveal his/her CC Password to anycne or store or record the CC Password in written or other form. Upon registration as a CC user, the Signatory will be assigned a unique identifying account name. B. Distribution, Initialization and Return of Tokens. 1. The Bank will physically deliver a Token to each Signatory in a manner to be determined by and satisfactory to the Bank. 2. At the time of delivery of a Token to a Signatory, the Signatory will receive a copy of these Terms and Conditions of Use for purposes of initializing the Token. 3. The Bank will verify that the Token, Temporary Password and Terms and Conditions of Use have been duly delivered to and receivec by the CC User. 4. Promptly upon receipt of the Token and Terms and Conditions of Use, the Signatory will access CC using his/her account name and CC Password and register his/her Token and set a personal "Bank" includes IBRD and IDA. 2 "Borrower" includes the borrower of an IBRD loan, IDA credit, or Project Preparation Facility advance and the recipien. of a grant. 7 identification number (PIN) to be used in connection with the use of his/her Token, after which the Token will be initialized for use by the Signatory exclusively for purposes of delivering Applications. Upon initialization of the Token, the Signatory will be a "Token User". The Bank will maintain in its database a user account (Account) for each Token User for purposes of managing the Token of the Token User. Neither the Borrower nor the Token User will have any access to the Account. 5. Prior to first use of the Token by the Token User for delivering Applications, the Borrower shall ensure that the Token User has received training materials provided by the Bank in use of the Token. 6. Tokens shall be promptly returned to the Bank upon request of the Bank. C. Management of Tokens. 1. Tokens will remain the property of the Bank. 2. Use of the Token is strictly limited to use in the delivery of Applications by the Token User in the manner prescribed by the Bank in the Agreement(s) and these Terms and Conditions. Any other use of the Token is prohibited. 3. The Bank assumes no responsibility or liability whatsoever for any misuse of the Token by the Token User, other representatives of the Borrower, or third parties. 4. The Borrower undertakes to ensure, and represents and warrants to the Bank (such representation and warranty being expressly relied upon by the Bank in delivery of a Token to each Token User) that each Token User is provided, understands and will abide by, these Terms and Conditions of Use, including without limitation the following: Security 4.1. The Token User shall not reveal his/her PIN to anyone or store or record the PIN in written or other form. 4.2. The Token User shall not allow anyone else to utilize a Token to deliver an Application to the Bank. 4.3. The Token User shall always logout from CC when not using the system. Failure to logout properly can create a route into the system that is unprotected. 4.4. If the Token User believes a third party has learned his/her PIN or has lost his/her Token he/she shall immediately notify cI ientconnectiongworldbank.org. 4.5. The Borrower shall immediately notify the Bank at clientconnection@worldbank.org of any lost, stolen or compromised Tokens, and take other reasonable steps to ensure such Tokens are disabled immediately. 8 Care of Tokens .4.6. Tokens contain delicate and sophisticated instrumentation and therefore should be )andled with due care, and should not be immersed in liquids, exposed to extreme temperatures, crushed or bent. Also, Tokens should be kept more than five (5) cm from devices that generate electromagnetic radiation (EMR), such as mobile phones, phone-enabled PDAs, smart phones and other similar devices. Tokens should be carried and stored separate from any EMR device. At close range (less than 5 cm), these devices can output high levels of EMR that can interfere with the proper operation of electronic equipment, including the Token. 4.7 Without derogating from these Terms and Conditions of Use, other technical instructions on the proper use and care Tokens are available at http://www.rsa.com. 5. Replacement 5.1. Lost, damaged, compromised (in terms of 4.5, above) or destroyed Tokens will be replaced at the expense of the Borrcwer. 5.2. The Bank reserves the right, in its sole discretion, not to replace any Token in the case of raisuse, or not to reactivate a Token User's Account 6. Reservation of Right to disable Token 6.1. The Borrower shall reserve the right to revoke the authorization of a Token User to use a Token for any reason. 6.2. The Bank reserves the right, in its sole discretion, to temporarily or permanently disable a Token, de-activate a Token User's Account or both. 9 Attachment 4 Form of Interim Financial Report (Separately attached) 10 FMR - Summary Sheet IDA Credit No....... IN Name of the Project Karnataka Health System Development and Reform Project Reference Period Expenditure Quarter Forecast for next two Units INR is lakhs For the expenditure q arter Forecast for next two quarters Actual expenditure Reimbursable Reimbursable Projected Reimbursable Reimbursable SI. No. Category No. for the quarter %age amount Expenditure %age amount 1 2 3 4 5 6 7 8 1 1 90% 90% 2 2 90% 90% Total of reimbursable categories 3 3 0% 0 0% 0 Total of non reimbursable category(State Govt. Co financing) Total Nues.1) Ciaimt undel evicaluai insurance Giairns(Caiegory 2), is io be submitted separaieiy on achievemeni of miesione Place: Bangalore Chief Finance Officer Date: KHSDRP, Bangalore  FMR - Karnataka Health System Development and Reforms Project Credit No. IDA...... - IN Category No. and Reimbursable Component for the period rom .......... to ........... Amount of the Amount Expenditure Reimbursable Amount Credit Allocated ofTheFrom Category (redin Sd Expenditures to be financed of the From ......... Project to Jrom (Expressed in SDR Credit to.........date .........to Project to date equivalent) Allocated ... .. (Expressed in INR Lakh equivalent) (1) Goods, works, services, 90% consultancies and operating expenses (2) Medical Insurance Claims under 90% Part B. 2 of the Project Total of reimbursable categories (3) Government of Karnataka - Co 0% financing Total Note: 1. Claim under Category 2 Medical Insurance Claims(Reimbursement of claims) is to be submitted separately on achievement of milestones. Place: Bangalore Chief Finance Officer Date: KHSDRP, Bangalore  rIVim - ruri EIdL riim -i Karnataka Health System Development and Reform Project(IDA Credit...... - IN) Financial Monitoring Report for the period from ....... to ............ Expressed in INR Lakh equivalent Budget Project Expenditure Code Budget Head Budget Provision for For the period Year to date Project to date the year ......... to ........ A. Project Components Part 1. Strengthening Existing Government Health Programs 2210-06-003-0-11 KHSDRP - Organisational Development - EAP 2210 2210-06-112-0-02 KHSDRP - Public Health Competitive Fund/NCD Prevention & Control and Road Safety & Emergency Health Services - EAP 2210-06-112-0-04 KHSDRP - Service Improvement Challenge Fund/Innovations in Service Delivery - EAP 4210-01-110-1-87 KHSDRP - Service Improvement Challenge Fund/Innovations in 4210 Service Delivery - EAP 139 - Major Works 180 - Machinery and Equipment 2210 Part 2. Innovations in Service Delivery and Health Financing 2210-06-112-0-03 KHSDRP - Health Financing - EAP* Part 3. Project Management, Monitoring and Evaluation 2210 2210-06-101-1-08 KHSDRP - Project Management and Evaluation - EAP 4210 4210-01-110-1-86 KHSDRP - Project Management & Evaluation - EAP A. Project Components total of which (i) Bank Share(90%) (ii) Government of KarnatakaShare(10%) B. Government of Karnataka - Co financing(100%) 2210 2210-80-001-0-01 Suvarna Arogya Suraksha 4210 4210-01-110-1-01 Buildings Hospital Construction/Upgradation J%.UV lI t l ilLUl llCktr,0 - MU 1I ali,ith_ LUL01 Grand total(A + B) F__ Bank share in the Grand total(%) Government of Karnataka share in the Grand total(%) _!E __ Total Certificates 1) FMR is prepared on the basis of Treasury Schedule(Reports) 62B. 2) Original documentsNouchers pertaining to the above expenditure are maintained in the Office of the Project Administrator, Chief Engineer, KHSDRP, Bangalore, EE, KHSDRP 3) *Claims under Category 2 - Medical Insurance Claims(Reimbursment of claims) is to be submitted separately on achievement of milestones.  FMR - Format FIN - 2 Karnataka Health System Development and Reform Project(IDA Credit..... - IN) Financial Monitoring Report for the period from. to...... Expressed in INR Lakh equivalent Expenditure for the period from ....... to ........ Budge Bde _____ ____ _____ t Code Budget Head provision for the year Salaries Operational Subsidiary Others Total Expenditure Expenses A. Project Expenditure 2210-06-003-0-11 KHSDRP - Organisational Development - EAP 2210-06-112-0-02 KHSDRP - Public Health Competitive Fund/NCD Prevention & Control and Road Safety & Emergency Health 2210 Services - EAP 2210-06-112-0-03 KHSDRP - Health Financing - EAP* 2210-06-112-0-04 KHSDRP - Service Improvement Challenge Fund/Innovations in Service Delivery - EAP 2210-06-101-1-08 KHSDRP - Project Management and Evaluation - 4210-01-110-1-86 KHSDRP - Project Management & Evaluation - EAP 4210-01-110-1-87 KHSDRP - Service Improvement Challenge 4210 Fund/Innovations in Service Delivery - EAP 139 - Major Works .180 - Machinery and Eauirment A. Project Components total B. Government of Karnataka - Co financing 2210 2210-80-001-0-01 Suvarna Arogya Suraksha 4210 4210-01-110-1-01 Buildings Hospital Construction/Upgradation Government of Karnataka - Co financing total Grand total(A+B) Notes: 1) Salaries means Pay of Officers, Pay of Staff and Other Allowances paid along with salary 2) Operational Expenditure means General Expenses and Other Expenses 3) Original documentsNouchers pertaining to the above expenditure are maintained in the Office of the Project Administrator, Chief Engineer, KHSDRP, Bangalore, EE, KHSDRP Divisions, AEE, KHSDRP Sub Divisions and DPMU Offices in all the Districts and are available for verification. 4) *Claim under Category 2 - Medical Insurance Claims(Reimbursment of claims) is to be submitted separately on achievement of milestones. Place: Bangalore Project Director Chief Finance Officer Date: KHSDRP KHSDRP, Bangalore  FMR - Format FIN - 3 Karnataka Health System Development and Reform Project Credit No. -IN Financial Monitoring Progress Report for the Period from ........... to ... Expressed in INR Lakh equivalent Government of Karnataka - Expenditure(Excluding Category 2 Expenditure Co financing(not eligible Cumulative Expenditure Category 2) for reimbursement) Budget Code For the Forthe For the For the period Year to Project period Year to Project to period Year to Project period Year to Project to from...... date to date from........ date date from...... date to date from........t date date ..to.. ..to to.................... ..o...... . 0........... (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)(2+5+8) (12)(3+6+9) (13)(4+7+10) Project Components Expenditure as per FIN 1 Reimbursement receivable on Actual Receipt from Government of India Add/Less: Exchange Add/Less: Audit Disallowance Adjusted Receipts from Gol(INR claimed) Notes: 1) Receipt from Gol is shown on the basis of amounts credited to GoK A/c up to ............ 2) Reimbursement of IDA share received in respect of claims up to end of ......quarter. 3) Claim under Category 2 - Medical Insurance Claims(Reimbursment of claims) is to be submitted separately on achievement of Place: Bangalore Project Director Thief Finance Officei Date: KHSDRP KHSDRP, Bangalore  FMR - Format FIN - 4 Karnataka Health System Development and Reform Project Credit No. - IN Financial Monitoring Progress Report for the Period from ......to...... Statement of reconciliation of World Bank Claims Expressed in INR Application No. Date Date of Claim amount Funds Cumulative Remarks submission received funds received Place: Bangalore Project Director Chief Finance Officer Date: KHSDRP KHSDRP, Bangalore s FMR - Format FIN - 5 Karnataka Health System Development and Reform Project Credit No. - IN Financial Monitoring Progress Report for the Period from ......to...... Expenditure Forecast for Particulars Cumulative to next 6 Current Qurter Year to date date next 6 months 1 3 4 5 6 Expenditure by Component: Component 1. Strengthening Subcomponent ]A. Organizational Development 0 0 0 0 Subcomponent IB. Improving Primary and Secondary Care Services' Effectiveness 0 0 0 0 Component 1 Total: 0 0 0 0 Component 2. Innovations in Service veivery ana nealtn Financing Subcomponent 2A. Innovations in Service Delivery 0 0 0 0 Subcomponent 2B. Innovations in Health Financing 0 0 0 0 Component 2 Total: 0 0 0 0 Component 3. Project Management, IMonitorina and Evaluation 0 0 0 0 Total 0.00 0.00 0.00 0.001 Project Director Chief Finance Officer KHSDRP KHSDRP, Bangalore  FMR - Karnataka Health System Development and Reform Project(IDA Credit..... - IN) List of Contracts/Work/Purchase Orders issued from ......... to SI. Agreement/Contrac Name of the Description of the UnitlQty. Contract/suppi Unit/month Agreementl No. t/Work/Purchase WBR No. Contractor/Agency/Suppli contract/work/supply ordered ylvalidity ly rate Contract/Wo Remarks Order No. & Date er on whom order placed to be executed period rk/Purchase 1 2 3 4 5 6 7 8 9 10 Inclusive/exclusive of Notes: 1) In the Remarks col. whether contract value is inclusive or exclusive of taxes may be indicated 2) Where the contract is monthly rated, period for which the contract is awarded(in terms of months or from... to...) may be indicated 3) In case of contracts for time related payments, total contract value in col. 9 to be indicated on the basis of monthly/period related rate(col. 8x period of the contract(col.7) Place: Bangalore Project Director Chief Finance Officer Date: KHSDRP KHSDRP, Bangalore  FMR - Karnataka Health System Development & Reform Project(IDA Credit..... - IN) Details of Payments under WBR Contracts from .......to ...... under Vr. No. Date of payment Bill amount Agreement/Contract/WorklPurc Name of the Contractor/Agency/Supplier to Description of the contractlwork/supply executed as per Form hase Order No. & Date WBR No. whom payment made 62B Note: Details of payments made under WBR contracts under each head of account in the reporting period to be detailed head of accountwise Place: Bangalore Project Director Chief Finance Officer Date: KHSDRP KHSDRP, Bangalore  FMR - Karnataka Health System Development & Reform Project(IDA Credit - IN) Payments for civil works under non WBR Contracts from ....... to ........ under(4210-01-110-1-87-139) Vr. No. Date of payment Bill amount Agreement/Contract/Work/Purc Name of the Contractor/AgencylSupplier Description of the contractlwork/supply executed as per Form 62B hase Order No. & Date to whom payment made 1 2 3 4 5 6 Total WBR payments Grand total 77___7_ Note: Details of payments made under non WBR contracts in the reporting period to be detailed Place: Bangalore Project Director Chief Finance Officer Date: KHSDRP KHSDRP, Bangalore Q FMR - Karnataka Health System Development & Reform Project(IDA Credit...... - IN) Details of Payments under WBR Contracts in........quarter and up to ........... Variatio n over % of Name of the WBR Original Contract/W.0 Description of Payments Cumulative Balance Original variation SI. Contractor/Agency/S Control WBR No. Contract .IP.O. value the Cumulative during payments up to pay as Contrac over Original Remarks No. upplier to whom No /W.O.JP. including contract/work/su payments up to .............. to ....... at ....... t/W.O./ Contract/W. payment made o. 0. value variations pply executed quarter P.O. O./P.O. value value 1 2 3 4 5 6 7 8 9 10(8+9) 11(5-10) 12(10-5) 13(12*100/5) 14 Place: Bangalore Project Director Chief Finance Officer Date: KHSDRP KHSDRP, Bangalore & a