V.

P-15,000/1-2000

1. Name of the child _________________________ 2. Date of last claim____________

3. Period for which reimbursed was 4. Period to which claim
Claimed______________________ pertains.__________________

No. Name of the School in which Class for Class in Monthly Amt.of Govt. Amt. Of Amt of reimbursement
Child studying (State which which tuition fee Scholarship if Scholarship claimed (to Restricted
or a Govt. claim studying paid actually any. sources fees as by the
added School). preferred (receipts authority)
attached)
1 2 3 4 5 6 7 8 9

Certified that my child/ children mentioned above in respect of whom reimbursement of tuition fees is/are studying in the
school mentioned in column 3 Which is /are recognized school and the tuition fees Indicated against which have actually been
paid me.

Certified that my wife/husband is not in the Govt. Service and that n imbursement would have claimed by her/him and also the
pay drawn by her/him does not exceed Rs. 1200/- p.m (Pre-revised).

My wife/husband is employed with ___________________________________ She/He is note entitled to reimbursement of

tuition fees in respect of children. She/He is entitled to reimbursement of tuition fees in respects of children as follows:-

(2)
Certified that I have not claimed and will not claim to children educational allowance under the Ministry of Finance, O.M. No.
10 (H). Estt. (Spl.,)/ 60 dt. 30.1.60 & 30.1.62 in respect of the children mentioned over-leaf (Strike out if not applicable).

Dated__________________________ SIGNATURE OF GOVT. SERVANT

Name__________________________
Designation_____________________
Branch/Deptt.____________________

VERIFICATION FROM SCHOOL AUTHORITIES:

1. Name of the School :_______________________________________
2. Certified that __________________son/daughter of Shri_________________ is a bonafied student of class________
of this School. Certified that he/she has not been studying for more than two academic Years in this class.________.
3. Certified that He/She is mot in receipt of Govt. or non-Govt, Scholarship
4. Certified that this is recognized school under the Directorate of Education, Delhi administration, Delhi.
5. Certified that _____________________-son/daughter of Shri________________________ has paid tuition fee/science
fee at the rate of Rs._____________________/- & Rs. ______________________________/- pm. respectively for
class_________for the period w.e.f

N.B.: (The certificate without stamp of the school be considered as invalid certificate)

PRINCIPAL OF THE SCHOOL