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Indian Institut Indian Institut Indian Institut Indian Institute of Technology e of Technology e of Technology e of Technology Guwahati Guwahati Guwahati

ati Guwahati
A C A D E M I C S E C T I O N
Form No. Gen Gen Gen Gen/ // /20 20 20 20
Contingency Expenses Reimbursement Form Contingency Expenses Reimbursement Form Contingency Expenses Reimbursement Form Contingency Expenses Reimbursement Form

1. Contingency A/c Code of the concerned academic Dept./Centre:_________________________________
2. Name of Claimant (in BLOCK letter): _______________________________________________________________
3. Programme (Please tick [ ] ]] ]): M. Tech / M. Des / Ph. D / M. Tech / M. Des / Ph. D / M. Tech / M. Des / Ph. D / M. Tech / M. Des / Ph. D / Dual (M. Tech + Ph. D) Dual (M. Tech + Ph. D) Dual (M. Tech + Ph. D) Dual (M. Tech + Ph. D)
4. Roll No.: _______________________________________________________________________________________
5. Department / Centre: ____________________________________________________________________________
6. Session: ________________________________________________________________________________________
7. Contact Phone No.: ______________________________________________________________________________
8. email: __________________________________________________________________________________________
9. Amount of reimbursement (Maximum Rs.5,000/- per annum):
________________________________________
10. Bank A/c No. of the claimant: _____________________________________________________________________
11. Name and Branch of Bank: ________________________________________________________________________

DETAILS DETAILS DETAILS DETAILS OF EXPENDITURE OF EXPENDITURE OF EXPENDITURE OF EXPENDITURE* ** *
Sl. No. Sl. No. Sl. No. Sl. No.
Description of Items Description of Items Description of Items Description of Items (Voucher (Voucher (Voucher (Voucher
No.) No.) No.) No.)
V VV Voucher oucher oucher oucher
Date Date Date Date
Qty. Qty. Qty. Qty. Rate Rate Rate Rate Total Amount Total Amount Total Amount Total Amount
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Total Expenditure Total Expenditure Total Expenditure Total Expenditure
Note: * To be submitted on one-time basis only latest by the month of February for a financial year.

(Rupees _______________________________________________________________________________________________ only)

Signature of Claimant Signature of Claimant Signature of Claimant Signature of Claimant
Certified that the reimbursement claim has been done on one on one on one on one- -- -time basis time basis time basis time basis for financial year

Recommended / Not-Recommended

HOD / H HOD / H HOD / H HOD / HA AA AC CC C

[Vouchers [Vouchers [Vouchers [Vouchers / Bills / Cash Memo / Bills / Cash Memo / Bills / Cash Memo / Bills / Cash Memos are to be attached chronologically with self attestation by the s are to be attached chronologically with self attestation by the s are to be attached chronologically with self attestation by the s are to be attached chronologically with self attestation by the Claimant Claimant Claimant Claimant] ] ] ]


For Office use only (ACADEMIC For Office use only (ACADEMIC For Office use only (ACADEMIC For Office use only (ACADEMIC SECTION SECTION SECTION SECTION) )) ): :: :

12. Whether the above referred person is a MHRD funded registered Regular M.Tech./M.Des/Ph.D./Dual (M.Tech +
Ph.D) student or not? [Yes/No] . If No, the status is


Dealing Assistant Dealing Assistant Dealing Assistant Dealing Assistant DR/AR(Acad.) DR/AR(Acad.) DR/AR(Acad.) DR/AR(Acad.) DOAA/ADOAA DOAA/ADOAA DOAA/ADOAA DOAA/ADOAA

For Office use only ( For Office use only ( For Office use only ( For Office use only (FINANCE & ACCOUNTS SECTION FINANCE & ACCOUNTS SECTION FINANCE & ACCOUNTS SECTION FINANCE & ACCOUNTS SECTION) )) ): :: :
Checked and passed for payment of `_____________________________ (Rupees ___________________________
______________________________________ only) towards the claim.


Dealing Assistant Dealing Assistant Dealing Assistant Dealing Assistant Accounts Officer (F&A) Accounts Officer (F&A) Accounts Officer (F&A) Accounts Officer (F&A) AR / AR / AR / AR / DR (F&A) DR (F&A) DR (F&A) DR (F&A)


R RR RE EE EG GG GI II IS SS ST TT TR RR RA AA AR RR R / // / D DD DI II IR RR RE EE EC CC CT TT TO OO OR RR R