FORM • C '

Vide Rule-15 (3)

APPLICATION FORM FOR CLAIMING REFUND OF MEDICAL EXPENSES
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Name and Designation of the Govt. Servant
(in Block Letters)
Office in which employed
Salary
Full Residential address
Place of Duty
Name Of the patient and his/her relationship
to the Govt. servant
( Note, in the
case of children, State e also
Nature of illness and its duration
Place at which the patient fell ill
Details for the amount claimed
Total amount claimed
List of Enclosures
Sri L KRISHNA HC 5630
Rajagopalanagara police Station.
36.950,'-
No .24. I Main Road. Venkateswara
Layout..Andrahalli Main Road, Herohalli
B' lore-91
Rajagopalanagara Police Station.
Mr. Kavan Sagar gowda. RK, 17 Yrs
Son
Fever & Decrese Blood Platelates
No .24, I Main Road. Venkateswara
Layout,Andrahalli Main Road, Herohalli
W lore-9i
Enclosed Medical Bills And Prescriptions
82 Paise
Rs. 27.843/- Ru
DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT
I hereby declared that the statement in this application are true to the best of my
knowledge
and belief and that the person for whom medical expenses were incurred in a member
of my family
as detailed under the Karnataka Government Servants ( Medical Affendence ) Rules,
1963. and is
wholly dependent upon me.
Place : Bangalore City
Date : 13.07.2019
Signature of the Government Servant