1. Number and date of writ.

2. Date when received.

3. From whom received.

4. Name and residence of judgment debtor.

5. Name and residence of judgment creditor.

6. Date of levy.

7. Total to be recovered up to the date of levy.

(a) Principal sum.

(b) Rate of interest and amount.

(c) Period of time for which interest to be reckoned.

(d) Costs.

(e) Mileage fee.

8. Amount actually recovered.

9. Amount of Mukhtar's account and his receipt.

10. Amount paid to judgment creditor and his receipt.

11. Amount paid to Treasury Clerk with number and date of his receipt.

12. Amount of surplus (if any) paid to judgment debtor and his receipt.

13. Remarks.