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Application form for grant of LTC advance

1. Name of the Government Servant
2. Designation
Date of entering the Central Government
3. Service
4. PAY + SI + NPA
5. Whether permanent or temporary
6. Home Town as recorded in the Service Book
Whether wife / husband is employed and if
7. so whether entitled to LTC
Whether the concession is to be availed for
8. visiting home town and if so block for which
LTC is to be availed.
(a) If the concession is to visit anywhere in
9. India, the place to be visited.
(b) Block for which to be availed.
Single rail fare/bus fare from the
10. headquarters to home town/place of visit by
shortest route.
Persons in respect of whom LTC is proposed to be availed.
S.No Name Age Relationship
1.
2.
11. 3.
4.
5.
6.
12. Amount of advance required. Rs. I declare that the particulars furnished above are true and correct to the best of my knowledge. undertake to produce the tickets for the outward journey within ten days of receipt of the advance.

In the event of cancellation of the journey or if I fail to produce the tickets within ten days of receipt of advance, I undertake to refund the entire advance in one lump sum.

Date

Signature of Government Servant.

G.A.R.14-C

Sub Bill No. _

LEAVE TRAVEL CONCESSION BILL FOR THE BLOCK OF YEAR~ TO __

Note:-- This bill should be prepared in duplicate-one for payment and the other as office copy.

PART - A (To be filled up by Government Servant)

1. Name of the Government Servant
2. Designation
3. PAY + SI + NPA
4. Headquarters
5. Nature and period of leave sanctioned
From To
6. Particulars of members of family in respect of whom the L.T.C. has been claimed.
S. Name (s) Age Relationship with the Government
No. Servant
1.
2.
3.
4.
5.
6.
7. Details of [ourne (s) performed by Government servant and the members of his/her family.
Departure Arrival Mode of Travel
Distance &. class of No of Fair
Date&. Date&. in Kms accommodation fares paid Remarks
Time From Time To used









8. Amount of advance, if any, drawn Rs. 9. I Particulars of journey (s) for which higher class of accommodation than the one to which the Government
servant is entitled was used. (Sanction No. & Date to be given.)
Place Mode of Class to which Class by No of Fare paid
conveyance entitled. which Fares
From To actually Rs. P.
travelled





10. I Particulars of journey (s) performed by road between places connected by rail
Nature of Place Class to which Rail fare
From To entitled Rs. P. Certified that the:-

1. Information, as given above is true to the best of my knowledge and belief; and

2. That my husband/wife is not employed in Government service / that my husband/wife is employed in government service and the concession has not been availed of by him/her separately or himself/herself

or for any of the family members of the concerned block of Years.

Date __

Signature of Government Servant

Part - B ( to be filled in the Bill Section)

1. The net entitlement on account of leave travel concession works out to Rs. as

detailed below:-

(a) Railway/Air/Bus/Steamer fare Rs. _

(b) Less amount of advance drawan vide

Voucher No dated Rs. _

Net Amount

Rs.

2. The expenditure is debitable to

Initial of Bill Clerk

Signature of Drawing &. Disbursing Officer

Counter signed

Certified that necessary

Shri/Shrimati/Miss, _

entries

have

been

made

Signature of Controlling Officer

in the Service Book of

Signature of the officer authorized to attest entries in the Service Book.

Passed for Rs Rupees .

Signature of Controlling Officer

FOR USE IN ACCOUNTS BRANCH L PAY AND ACCOUNTS OFFICE

VOUCHER NO DATED .

Pay Rs •..•..•..•..•..•..•..•..•..•..•..•..•.... Rupees .

Vide Cheque No dated .

Signature of the Drawing and Disbursing Officer

LTC CERTIFICATE

CERTIFICATES TO BE GIVEN BY THE CONTROLLING OFFICER

Certified:

(i) that Shri/Shrimati/Kumari (Name of the Govt. Servant) ..

Has rendered continuous service for one year or more on the date of commencing the outward journey.

(ii) that necessary entries as required under para 3 of the Ministry of Home Affairs O.M. No.43/1/55-Ests.(A) Part II dated n" October, 1956 have made in the Service book of Shri/Shrimati/Kumari

Signature &. Designation of the Controlling Officer

CERTIFICAT TO BE GIVEN BY THE GOVT. SERVANT

1. I have not submitted any other claim so for Leave Travel Concession in respect of myself or my

family members in tlo the block of the years and .

2. I have already drawn TA for the Leave Travel Concession in respect of journey performed by

me/my wife with children. The claim is in respect to the journey performed

by my wife/myself with children none of whom traveled with the party on

the earlier occasion.

3. I have not already drawn TA for the Leave Travel Concession in respect of a journey performed

by me/my wife with children/ children in respect of the

block of two years and This claim is in respect of

the journey performed by my wife with children/ children

none of whom availed of the concession relating to that block.

4. I have already drawn TA for the Leave Travel Concession in tlo a journey performed by me in

the year in tlo of block of two

years and This claim is in tlo of the journey performed by me

in the year This is against the concession admissible once every year

in a prescribed block for visiting home town as all the members of my family are living away from place of work.

5. The journey has been performed by me/my

wife children/ children to the declare home town

viz .

6. That my husband/wife is not employed in Government.

That my husband/wife is employed in Government Service and the concession has not been availed of by him/her separately for himself/herself or for any of the family members for the concerned block of two years.

7. Certified that my wife/husband for whom L.T.C. is claimed by me is employed in

........................................................................................ (Name of the Public Sector

Undertaking/Corporation/Autonomous body etc.) which provides Leave Travel Concession facilities but he/she has not preferred and will not prefer, any claim in this behalf from his/her employer.

8. Certified that my wife/husband for whom L.T.C. is claimed by me is not employed in any Public Sector Undertaking/Corporation/Autonomous body financed wholly or partly owned by the Central Government Local Body which provides L.T.C facilities to its employees and their families.

Signature of Government Servant

CONVEYANCE HIRE CLAIM

1. Name of the Government Servant
2. Designation
3. Officer I Section to which attached
4. Department Name
10. Particulars of journey for which conveyance is claimed.
Date of Journey &. Particulars Mode of Distance Purpose of Amount
time conveyance in Kms Journey Spent in
Date Time From To Rs.
1 2 3 4 5 6 7 8 Note:- In case of Taxi I Scooter hire the Registration No of the vehicle should be quoted and fare receipt be enclosed.

Date _

Signature of the Claimant _

Name and Designation of the Claimant. _

G.A.R. 14 -- A

Sub Bill No. _

TRA VELLING ALLOWANCE BILL FOR TOUR

Note: - This bill should be prepared in duplicate - one for payment and the other as office copy

PART - A ( To be filled up by Government Servant)

1. Name of the Government Servant
2. Designation
3. PAY + SI + NPA
4. Headq ua rters
S. Details and purpose of journey (s) performed.
Departure Arrival Mode of Travel Fair paid Distance Duration Purpose of
& class of in Kms for of Halt Journey
Date & Time From Date & To accommodation road
Time used mileage

1 2 3 4 5 6 7 8 9








6. Mode of journey:
(i) Air
(a) Exchange voucher arranged by office Yes/No
(b) Ticket /Exchange voucher arranged by
(ii) Rail
(a) Whether traveled by mail/express/ordinary train? Yes/No
(b) Whether return tickets available?
(c) If available whether return tickets purchased? If not, state reasons
(iii) Road
Mode of conveyance used, i.e. by Government transport/by taking a
taxi, a single seat in a bus or other public conveyance/by sharing with
another Government servant in a car belonging to him or to a third per
to be specified.
7. Dates of absence from place of halt on account of
(a) R.H. and c.i,
(b) Not being actually in camp on Sundays and holidays. 8. Dates on which free board and lor lodging provided by the State or any
organization financed by State funds:
(a) Board Only
(b) Lodging only
(c) Board and lodging.
9. Particulars to be furnished along with hotel receipts, etc., in cases where higher rate of D.A. is claimed for stay
in hotel I other establishments providing board and I or lodging at scheduled tariffs.
S.No Period of Stay Name of the hotel Daily rate of lodging Total amount
From To charged in Rs. Paid Rs.
1.
2.
3.
4.
5.
10. Particulars of journey(s) for which higher class of accommodation than the one to which the Government
servant is entitled was used.
S.No Date Name of places Mode of Class to Class by Fare of the
From To conveyance which which entitled class
1 2 3 4 used entitled travelled Rs. P.
5 6 7 8
1.
2.
3.
4.
S.
If the journey(s) by higher class of accommodation has been
performed with the approval of competent authority, No and
date of the sanction may be quoted.
11. Details of journey (s) performed by road between places connected by rail.
S.No Date Nature of Place Rail fare
From To Rs. P.
1 2 3 4 5



12. Amount of T.A. advance, if any, drawn Rs. Certified that the information, as given above, is true to the best of my knowledge and belief.

(

)

Signature of the Government Servant

Date. _

Part - B ( to be filled in the Bill Section)

1. The net entitlement on account of Travelling Allowance works out to Rs. _

as detailed below:-

(a) Railway/Air/Bus/Steamer fare Rs.
(b) Road Mileage for Kms.

@ per/kms

(c) Daily allowance
(i) days @ Rs per day.
(ii) days @ Rs per day.
(iii) days @ Rs per day.
Rs.
(d) Actual expenses Rs.
Gross amount Rs.
(e) Less amount of T.A.advance, if any, drawan vide
Voucher No dated Rs.
Net Amount Rs. 2. The expenditure is debitable to

Initial of Bill Clerk

Signature of Drawing &. Disbursing Officer

Counter signed

Signature of the Controlling Officer

CERTIFICATES

1. Certified that limy family was neither allowed free transit by Rail under free pass or otherwise provided with means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in this bill.

2. Certified that limy family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the establishment.

4. Certified that the journey on was performed by Mail/Express train in the interest public

service,

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at. from

. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. to while on inspection duty

continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the higher rates rule 46 of Supplementary rule by taking a single seat in a taxilmotor or mini bus or lorry playing for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed ill Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.

The number of kilometers actually traveled by road being .

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum claimed in the bill.

14. Certified that I have transported kgms. of

luggage on my transfer from to .

Signature of the claimant

Counter singed

( Signature & Designation of the Controlling Officer)

G.A.R. 14 -- B

[ See Rule 66 (1) & 90 (1), (I) ]

Sub Bill No. _

TRA VELLING ALLOWANCE BILL FOR TRANSFER

Note: - This bill should be prepared in duplicate - one for payment and the other as office copy

PART - A (To be filled up by Government Servant)

1. Name
2. Designation & Office
3. PAY at the time of transfer Rs.
4. Headq ua rters (a) Old
(b) New
S. Residential Address (a) Old
(b) New
11. Particulars of the members of the family as on the date of transfer [vide S.R.2 (8) ] :
S.No Name Age Relationship
1. 2 3 4
1.
2.
3.
4.
S.
s. I Details of journey(s) performed by the Government servant as well as members of his/her family.
Departure Arrival Mode of Travel No of Fare paid Distance in
& class of fares Rs. Kms for road
Date & Time From Date & Time To accommodation
used
1 2 3 4 5 6 7 8 6. Transportation charges for personal effect (Money Receipts to be attached.
Date Mode of Station Weight Rate Amount Remarks
transport From To in Kgs. Rs. Rs.
1 2 3 4 5 6 7 8



7. Transportation charges for personal conveyance (Money receipt to be attached)
(a) Mode of transport and station to which transported.
(b) Amount. Rs.
8. Amount of T.A. advance, if any, drawn Rs.
9. Particulars of journey(s) for which higher class of accommodation than the one to which the Government servant
is entitled was used.
S. Date Name of places Mode of Class to Class by Fare of the
No conveyance which which entitled class
From To used entitled travelled Rs. P.
1 2 3 4 5 6 7 8
1.
2.
3.
4.
S.
If the journey(s) by higher class of accommodation has been
performed with the approval of competent authority, No and
date of the sanction may be quoted.
11. Details of journey (s) performed by road between places connected by rail.
S.No Date Nature of Place Rail fare
From To Rs. P.
1 2 3 4 5 Certified that the information, as given above, is true to the best of my knowledge and belief.

(

)

Daw _

Place ___

Signature of the Government Servant Name

----------------

Part - B ( to be filled in the Bill Section)

1. The net entitlement on account of Travelling Allowance works out to Rs. _

(Rupees _

as detailed below:-

(a) (b)

Railway/Air/Bus/Steamer fare

Rs. _

Road Mileage for Kms.

@ per/kms

(c)

Composite transfer grant

Rs. _

(d) Transportation of personal effects Rs. _

(e) Transportation of private conveyance Rs. _

(f) (g)

Gross amount ( (a) + (b) + (c) + (d) + (e) )

Rs. _

Less amount of advance(s), if any, drawan vide

Voucher No dated _

Rs. _

Net Amount( f-G) Rs.

2. The expenditure is debitable to

Initial of Bill Clerk

Signature of Drawing &. Disbursing Officer

Counter signed

Signature of the Controlling Officer

CERTIFICATES

1. Certified that limy family was neither allowed free transit by Rail under free pass or otherwise provided with means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in this bill.

2. Certified that limy family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the establishment.

4. Certified that the journey on was performed by Mail/Express train in the interest public

service,

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at. from

. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. to while on inspection duty

continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the higher rates rule 46 of Supplementary rule by taking a single seat in a taxilmotor or mini bus or lorry playing for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed ill Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.

The number of kilometers actually traveled by road being .

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum claimed in the bill.

14. Certified that I have transported kgms. of

luggage on my transfer from to .

Signature of the claimant

Counter singed

( Signature & Designation of the Controlling Officer)

Performa for application for advance from Provident Funds Application for Advance from G.P.F.

1. N arne of the Subscriber
2. Account Number
3. Designation
4. Pay Rs.
5. Balance at Credit of the subscriber on the date of application as below:-
i Closing balance as per statement for the Rs
year

11 Credit from to on Rs
account of monthly subscription.
... Refunds Rs
III
IV Withdrawals during the period from Rs
to

V Net balance at credit Rs
6. Amount of advance/outstanding, if any, and the
7. Amount of Advance required
8. a. Purpose for which the advance is required
b Rules under which the request is covered
c If advance is sought for House Building etc., following information may be given:-
i Location & measurement of the plot
11 Whether plot is freehold or on lease
... Plan for construction
III
IV If the flat or plot being purchased is
from a H.B. Society, the name of
Society, the location &
measurement, etc.
v Cost of construction
VI If the purchase of flat is from DDA
or any Housing Board etc., the
location, dimension, etc., may be
given.
d If advance is required for education of children, following details may be given:- i N arne of the son I daughter
11 Class & Institution I College where
studying
... Whether a day-scholar or a hostler
III
e If advance is required for treatment of ailing family members, following details may
be given:-
i Name of the patient and
relationship
11 N arne of the Hospital I Dispensary
IDoctor where the patient IS
undergoing treatment.
... Whether outdoor I indoor patient
III
IV Whether reimbursement available
or not
9 Amount of the consolidated advance (Items 6 Rs. ill ----
and 7 ) and number of monthly installments in Installments.
which the consolidated advance is proposed to
be repaid.
10 Full Particulars of pecuniary circumstances of
the subscriber, justifying the application for the
advance I certify that particulars given below are correct and complete to the best of my knowledge and belief and that nothing has been concealed by me.

Date:-

Signature of the Applicant

Name _

Designation _

Section I Branch _

Note:- In case of advance under 8 © to 8 (e), no certificate or documentary evidence would be required.

Performa for application for withdrawal from Provident Funds Application for Advance from G.P.F.

1. N arne of the Subscriber
2. Account Number
3. Designation
4. Pay Rs.
5. Date of Joining service and date of
Superannuation
5. Balance at Credit of the subscriber on the date of application as below:-
i Closing balance as per statement for the Rs
year

11 Credit from ---- to on Rs
account of monthly subscription.
... Refunds made to the Fund after the closing Rs
III
balance, vide (i) above
IV Withdrawals during the period from Rs
to

V Net balance at credit on date of application Rs
6. Amount of Advance required
8. a. Purpose for which the withdrawal IS
required
b Rules under which the request is covered
9 Whether any withdrawal was taken for the same
purpose earlier. If so, indicate the amount and the
year.
10 Name of the PAO maintaining the Provident Fund
Account Date:-

Signature of the Applicant

Name __

Designation _

Section / Branch _

Annexure-D Forms

1

Form of Application for Final Payment/Transfer to Corporate Bodies/Other Governments of Balances in the

General Provident Fund Account

To

The Pay and Accounts Officer,

(Through the Head of Office)

Sir,

I am to retirelhave retired have proceeded on leave preparatory to retirement for ____________ month s/h ave been dischargedldismissedlhave been

permanently transferred to / have resigned finally from

Government servicelhave resigned service under Government to

take up appointment with and my resignation has been accepted with effect

from forenoon/afternoon. I joined service with

on forenoon/afternoon.

2.

My Provident Fund Account No. is _

3. I desire to receive payment through my office through the __________ Treasury/Sub Treasury. Particulars of my personal marks of identification left hand thumb and finger impressions ( in the case of illiterate subscribers and specimen signature ( in case of literate subscribers) in duplicate, duly attested by a Gazetted Officer of the Government, are enclosed.

PART-I

[To be filled in when the application for final payment is submitted up to one year prior to retirement]

4. I request that the amount of Rs. standing to the credit in my

Provident Fund Account as indicated in the Accounts Statement issued to me for the yar _________ (enclosed) / as appearing in my ledger account being maintained by you Treasury/Sub Treasury/Head of Office, my please be arranged to be paid to me as first installment of final payment.

5. * * * * * *

6. After payment of the first installment of my Provident Fund balance, I will apply for the payment of subsequent installments in Part-II of the form immediately on retirement.

Yours faithfully

Station-------------

S ignature-- -- --- - - - -- - -- -- - - -- -- - -- - -- -Name

Date:- _

Address

This applies only when payment is not desired through the Head of Office.

( FOR USE BY HEADS OF OFFICES)

Forwarded to the Pay & Accounts Officer _

necessary action.

for

2. The Provident Fund Account No. _

of Shri/Shrimati/Kumari

(as certified from the Statements furnished to him! her from year to year ) is

3. He/She

IS

due

to

retire

from

Government

Service

on _

4. Certified that he/she had taken the following advances In respect of which instalment of Rs. are yet to be recovered and credited to the Fund Account. The details of the final withdrawals granted to him/her are also indicated below:-

Temporary Advances

Final Withdrawals

1. _

2. _

3. _

4. _

5. * * * * * *

Signature of the Head of Office

PART-II

[To be submitted by the Subscriber immediately after his/her retirement.

This Part is also applicable in the case of subscribers who apply for final payment for the first time after the date of superannuation, discharge, resignation etc. ]

In continuation of my earlier application, dated

for the final payment of Provident Fund balances, I request that the entire balance at my credit with interest due under the rules may be paid to me.

Or

I request that the entire amount at my credit with interest due under the rules may

be paid to me /transferred to _

Signature-------------------------------

Name _

Address _

( FOR USE BY HEADS OF OFFICES)

Forwarded to the Pay & Accounts Officer_________ for

necessary action/in continuation of Endorsement No. dated _

2. He/She has finally retired! will proceed on leave preparatory to retirement for ____________ monthslhave been discharged!dismissedlhave been

permanently transferred to / have resigned finally from

Government servicelhave resigned service under Government to

take up appointment with and my resignation has been accepted with effect

from forenoon/afternoon. He/She joined service

with on forenoon/afternoon.

3. The last fund deduction was made from his/her pay In this office bill

No. dated for Rs.

-------

(Rupees ), cash voucher No. _

_________ Treasury, the amount of deduction being Rs. _

and recovery on account of refund of advance Rs. _

of

4. Certified that he/she was neither sanctioned any tempory advance nor any final withdrawal from his/her Provident Fund Account during the 12 months immediately preceding the date of his Iher quitting service under ___________ Government/proceeding on leave preparatory to retirement

or thereafter

or

Certified that the following temporary advances/final withdrawals were sanctioned to him/her and drawn from his/her Provident Fund Account during the 12

months immediately preceding the date of his/her quitting service

under Government/proceeding on leave preparatory to

retirement or thereafter

Amount of Advance/withdrawal

Date

Voucher number

l. _

2. _

3. _

4. _

5. * * * * * *

6. It is certified that no demands/following demands of Government are due for recovery'.

7. Certified that he/she has not resigned from Government service with prior permission of the Central Government to take up an appointment in an other Department of the Central Government or under a State Government or under a body corporate owned or controlled by the State2.

Signature Of the Head of Office/Department

l. Certificate No.6 to be furnished in the case of Contributory Provident Fund Only. 2. Please score out if not necessary.

FORM OF APPLICATIONS FOR MEDICAL CLAIMS

MED.97

Form of application for claiming refund of medical expenses incurred in connection with medical attendance and/or treatment for Central Government servants and their families - for medical attendance/treatment taken both from the Authorised Medical Attendant and a Hospital

1. Name and designation of Government servant (in block letters)
i) Whether married or unmarried:
ii) If married, the place where wife/husband is Employed
2. Office in which employed
3. Pay of the Government servant as defined in the Fundamental Rules, and any
other emoluments which should be shown separately
4. Place of duty
5. Actual residential address
6. Name of the patient and his/her relationship to the Government servant. N.B.
- In the case of children state age also
7. Place at which the patient fell ill
8. Details of the amount claimed
I. Medical Attendance -
i) Fees for consultation indicating -
a) The name and designation of the Medical Officer consulted and the hospital or
dispensary to which attached
b) The number and dates of consultation and the fee paid for each consultation.
c) The number and dates of injection and the fee paid for each injection.
d) Whether consultations and/or injections were had at the hospital, at the consulting:
room of the medical officer or at the residence of the patient.
ii) Charges for pathological, bacteriological, radiological, or other similar tests
iundertaken during diagnosis indicating-
a) The name of the hospital or laboratory where undertaken; and
b) Whether the tests were undertaken on the advice of the authorized medical
attendant. If so, a certificate to that effect should be attached.
iii) Cost of medicines purchased from the market
(Cash memos and the essentiality certificate should be attached).
II Hospital Treatment.
Name of the hospital
Charges for hospital treatment, indicating separately the charges for -
i) Accommodation (State whether it was according to the status or pay of the:
Government servant and in cases where the accommodation is higher than the status
of the Government servant, a certificate should be attached to the effect that the
accommodation to which he was entitled was not available)
ii) Diet
iii) Surgical operation or medical treatment or confinement.
iv)Pathological, bacteriological, radiological or other similar tests indicating -
a) The name of the hospital or laboratory at which undertaken, and
b) Whether undertaken on the advice of the: medical officer in charge of the case at
the hospital. If so, a certificate to that effect should be attached.
~) Medicines.
~i) Special medicines (Cash memos and the essentiality certificates should be:
attached)
~ii) Ordinary nursing
~iii) Special nursing, i.e., nurses, specially engaged for the patient. State whether they:
are employed on the advice of the medical officer in charge of the case at the hospital
or at the request of the Govt. Servant or patient. In the former case a certificate from
the medical officer in charge of the case and countersigned by the Medical
Superintendent of the hospital should be attached.
ix) Ambulance charges (State the journey - to and from- undertaken)
NOTE 1. - If the treatment was received by the Govt. servant at his residence under Rule 7 of the C.S. (M.A)
Rules, 1944 give particulars of such treatment and attached a certificate from the authorized medica
attendant as required by these rules.
NOTE 2. - If the treatment was received at a hospital other than a Govt. hospital, necessary details and the certificate of the authorized medical attendant that the requisite treatment was not available in the nearest
Govt. hospital should be furnished.
III. Consultation with Specialist - Fees paid to a specialist or a Medical Officer other
than the authorized medical attendant, indicating -
a) The name and designation of the Specialist or Medical Officer consulted and the
hospital to which attached.
b) Number and dates of consultations and the fees charged for each consultation.
c) wherever consultation was had at the hospital, at the consulting room of the:
Specialist or Medical Officer, or at the residence of the patient, and
d) Whether the Specialist or Medical Officer was consulted on the advice of the
authorized medical attendant and the prior approval of the Chief Administrative:
Medical Officer of the State was obtained. If so, a certificate to hat effect should be
attached.
9. Total amount claimed
10. Less advance taken on
11. List of enclosure DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statement in the application are true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is wholly dependent upon me.

Dated .

Signature of the Government servant and Office to which attached.

ESSENTIALITY CERTIFICATE CERTIFICATE'A'

(To be completed in the case of patients who are not admitted to hospital for treatment)

Certificate granted to Mrs./Mr./Miss... Wife/ Son/ Daughter of

MR/MRS/MISS employed in the .

I, Dr.

................ hereby certify:-

(a) that I charged and received Rs for consultations on (dates to be

given) at my consulting room/ at the residence of the patient;

(b) that

charged and received Rs......... .... ..... for administering

intra-venous/intra-

muscular/subcutaneous injections on (dates to be given) at my consulting

Room/the residence of the patient;

(c) that the injections administered were not/were for immunising or prophylactic purposes;

(d) that the patient has been under treatment at hospital/ my consulting room and

that the undermentioned medicines prescribed by me in this connection were essential for the recovery/ prevention of serious deterioration in the condition of the patient. The medicines are not stocked in the .............. .... ... .... ... .... ... .... ... (name of the hospital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available nor preparations which are primarily food, toilets or disinfectants.

Name of Medicines

Price

2. 3. 4.

(e) that

the

patient

is/was

suffering

from

and

is/was under my treatment from to ;

(f) that the patient is/was not given pre-natal or post-natal treatment;

(g) that the X-ray laboratory test, etc., for which an expenditure of Rs was incurred was necessary

and were undertaken on my advice at (name of the hospital or laboratory);

(h) that I referred the patient to Dr. for SPECIALIST consultation and that the

necessary approval of the (Name of the Chief Administrative Officer of the State) as

required under the rules was obtained;

(i) that the patient did not require/required hospitalisation.

Dated:-----------

Signature of AMA/ Designation of the Medical officer and hospital/ dispensary to which attached.

N.B.:-certificates not applicable should be struck off. Certificate (e) is compulsory and must be filled in by the medical officer in all cases.

ESSENTIALITY CERTIFICATE CERTIFICATE-B

(To be completed in the case of patients WHO ARE ADMITIED to Hospital for treatment)

Certificate granted to Mrs.y Mr.y Miss wife /son/daughter of Mr./ Mrs./ Miss

................................. employed .

PART-A

I, Dr. hereby certify :-

(a) that the patient was admitted to hospital on the advice of . .... ... .... ... .... .... ..... (name of the medical officerl /on my advice;

(b) that the patient has been under treatment at and that the undermentioned medicines prescribed

by me in this connection were essential for the recovery/prevention of serious deterioration in the

condition of the patient. The medicines are not stocked in the .

(name of the hospital) for supply to private patients and do not include proprietary preparations for which cheaper substances of equal therapeutic value are available not preparations which are primarily foods, toilets or disinfectants.

NAME OF MEDICINES

PRICE

1 .

2 .

3 .

4 .

5 .

(c) that the injections administered were/were not for immunising of prophylactic purposes;

(d) that the patient is/was suffering from and is/was under treatment from to

(e) that the X-ray, laboratory test etc. for which an expenditure of Rs was incurred were necessary

and were undertaken on my advice at (name of hospital or laboratory);

(f) that I called on Dr. for specialist consultation and that the necessary approval of

the (name of the Chief Administrative Medical Officer of the State) as required under the

rules,

was

obtained.

Signature and Designation of the Medical Officer-in-charge of the case at the hospital.

PARTB

certify that the patient has been under treatment at the hospital and that the service of the

special nurses for which an expenditure of Rs was incurred, vide bills and receipts attached, were

essential for the recovery/prevention of serious deterioration in the condition of the patient.

Signature of the Medical Officer-in-charge of the case at the hospital.

COUNTERSIGNED

* I certify that the patient has been under treatment at the hospital and that the facilities

provided were the minimum which were essential for the patient's treatment.

Place .

Medical Superintendent ..................... Hospital

NOTE:- CERTIFICATES NOT APPLICABLE SHOULD BE STRUCK OFF. CERTIFICATE (B) IS COMPULSORY AND MUST BE FILLED IN BY THE MEDICAL OFFICER IN ALL CASES.