Application for Reimbursement of Tution Fees

ANNEXURE

1)       Name of the Government Servant                           :

2)       Designation and Office                                 :

3)       Date of the last claim                                   :

4)       Period for which reimbursement was claimed         :

5)       Period for which present claim pertains                  :

Name of the Child	Date of Birth	School in which studying & location of the School (State also it is a Govt. or Govt. Aided School)	Class in which Studying	Monthly Tuition fee paid actually (Receipt to be attached)	Amount of  Govt. Scholarship	Amount of Scholarship received from other sources (Merit scholarship specially earmarked for items)	Amount of reimbursement claimed (to be restricted to fees approved by Education Authorities

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CERTIFICATE

1)       Certified that the child mentioned below in respect of whom reimbursement of tuition fee is claimed is wholly dependent upon me.

2)       Certified that the tuition fees indicated against the child/ each of the children had actually been paid by me vide certificate(s) from the Institution attached.

3)       Certified that:-

i)        My wife/ husband is/is not a Central Government Servant.

ii)       My wife/ husband is Central Government Servant and his/her pay does not exceed Rs.__________ but he/ she will not claim reimbursement of tuition fee in respect of our child.

iii)      My wife/ husband is employed with _______________________________________________ he/ she is/is not entitled to reimbursement of tuition fees in respect of our child.

4)       Certified that during the period covered by this claim, the child attended the School regularly and did not absent himself/ herself from the school without proper leave for a period of exceeding one month.

5)       Certified that the child mentioned has not been studying in the same class for more than the two years.

6)       Certified that I or my wife/ husband has not claimed and will not claim the childrens’ educational allowance in respect of the children mentioned above (under the Ministry of Finance, OM No.F10(i) Estt/SPLO)/60 dated 10-1-1962 in respect of the children above.

7)       In even of any change in the particulars given above which affect my eligibility for reimbursement of tuition fee, I undertake to intimate the same promptly and also to refund excess payment if any made.

Signature of the Govt. Servant            :

Name in BLOCK   

LETTERS               :

Designation & Office: