FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDNCE AND OF TREATMENT OF CENTRAL GOVT. SERVANT AND THEIR FAMILIES. 1. Name & designation of the Govt. Servant. 2. Office in which employed. 3. Pay of the Govt. servant as defined in the fundamental rules and any other employments which should be shown separately 4. Place of duty 5. Actual residential address 6. Name of the patients & his / her Relationship to the Govt. servant. 7. Place at which the patient fell ill 8. Details of the amount claimed I MEDICAL ATTENDANCE. (a) The name & designation of the Medical officer consulted & the Hospital or dispensary to which attached. (b) The number & dates of consultation Of the Medical officer consulted And the Hospital or dispensary to Which attached. (c) Cost of medicines purchased form The market (list of medicines each Memos should be attached. 9. Total amount claimed 10. List of enclosures -............... -.............. -.............. -.............. -.............. -.............. -.............. -.............. -.............. -.............. -.............. -.............. -.............. DECLARATION TO BE SIGNED BY THE GOVT. SERVANT. I, hereby declare that the statement in this application is true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me. Signature of the Government servant and office to which attached.
