FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES

INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE AND/OR TREATMENT

OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES FOR MEDICAL
ATTENDANCE/TREATMENT TAKEN BOTH FROM AN AUTHORISED MEDICAL
ATTENDANT AND AT HOSPITAL

1. No. Rank and Name of the Govt. Servant : CISF NO. 962293337

(In block letters) Rank Constable/Fire

Name P.Govinda

(a) Whether married or unmarried : Merried

(b) If married, the place where wife / : No

Husband is employed

2. Office in which employed : CISF FSTI NISA Hakimpet, Hyderabad

3. Pay of Govt. Servant defied in the FR and : Rs. 37000/-

Any other emoluments which should be

Shown separately

4. Place of Duty : CISF FSTI NISA Hakimpet, Hyderabad

5. Actual Residential Address : Qno,117/1,CISF,FSTI,NISA,Hakimpet,

Hyd

6. Name of the Patient and his / her relation- : P.Kusuma Daughter 18years

Ship with the Govt. Servant (In case of

 Children, stage age also)

7. Place at which the patient fell ill : NISA HOSPITAL

8. Total amount claimed : Rs:- 1593.60

9. Less advance taken on : NIL

10. Net Amount claimed : Rs:- 1593.60

11. List of Enclosures : TWO

DECLARATION TO BE SIGNED BY THE GOV ERNMENT SERVANT

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

Date : Signature of the Individual