MEDICAL REIMBURSEMENT FORM

Name of Employee: Sanobar Khan EMP #:____________________

Designation: Associate Software Engineer Team:________RPA_____________

Reimbursement Details:

Date of Receipt Patient/Relationship Expense Type Amount (Rs)

Service No.
07/03/2022 394433 Mother Medical Expense 3,176
07/03/2022 127135 Father Medical Expense 15,495

Total Amount in Words: Eighteen thousand six hundred seventy-one

Expense Types: Medical Expense

Declaration:
I HEREBY DECLARE THAT the information provided in this form is true to the best of my knowledge & belief and that the
person for whom medical expenses were incurred is wholly dependent upon me.

Claimant’s Signature: ___Sanobar khan Date: ______11/03/2022______________

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Note: Please attach all relevant prescriptions and receipts.