Flowserve

* Medical reimbursement claim for the FY 2015-16

This is to confirm that I have spent the amounts specified below during the Financial year 2015-16
towards
Medical Exependiture

Sl.No. Bill No Date Self / Relationship Name of the Patient Amount

1 439 6/25/2015 Mother Ramala bibi 7530.5

2 943 12/6/2015 Mother Ramala bibi 7858

Total 15,388.50

Note:
* Actual expenditure incurred by the employee on medical treatment of self, spouse, children & parents
* Bills of cosmetics / toiletries not allowed

I hereby declare that the information furnished above is true and correct to the best of my knowledge.
Under any circumstance if the information is found to be incorrect or misstated I shall be held
personally liable and responsible for any legal / financial consequences resulting therefrom and they
shall be binding on me whether monetary or otherwise. Further, I understand that under no
circumstances the Company shall be held liable for any obligation arising therefrom.

Signature :

Name : MOHAMED RAFEEK

Emp. No. : 10137127

Date : 12/1/2016