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:

CERTIFICATES TO BE GIVEN BY THE GOVERNMENT SERVANT ON LTC

CERTIFICATES TO BE GIVEN BY THE

GOVERNMENT SERVANT ON LTC

            1. I have not submitted any other claim so far for Leave Travel Concession in respect of my self or my family members in respect of the block of the years ________   and __________         

            2. I have already drawn T.A. for the Leave Travel Concession in respect of a journey performed by me/my wife with _________________ children.  This claim is in respect of the journey performed by my wife/myself with _____________    children none of whom traveled with the party on the earlier occasion.

            3. I have not already drawn T.A. for the Leave Travel Concession in respect of a journey performed by me/my wife with  ___________     children/  _________   children in respect of the block of two years  ___________       and  __________  . This claim is in respect of the journey performed by my wife/myself with _________                    children/  ___________  children none of whom availed of the concession relating to that block.

            4. I have already drawn T.A. for the Leave Travel Concession in respect of a journey performed by me in the year, ____________ in respect of block of two years __________and  __________  This claim is in respect of the journey performed by me in the       year ___________  This is against the concession admissible once every year in a prescribed block for visiting hometown as all the members of my family are living away from my place of work.

            5. The journey has been performed by me/my wife with ___________ children/ ___________ children to the declared home town viz. ____________

            6. That my husband/wife is not employed in Government service       

                That my husband/wife is employed in Government service

and the concession has not been availed of my him/her separately for himself/herself or for any of the family member for the concerned block of two years.

            7. Certified that my wife/husband for whom L.T.C. is claimed by me is employed in

   ______________ ( name of the Public Sector Undertaking/Corporation/ Autonomous body etc.) which provides Leave Travel Concession facilities but he/she has not preferred and will not prefer, any claim in this behalf to his/her employer.                                            

            8. Certified that my wife/husband for whom L.T.C. is claimed by me is not employed in any Public Sector Undertaking/Corporation/Autonomous Body financed wholly or partly by the Central Government or a Local Body, which provides L.T.C facilities to its employees and their families.

Station:                                              

Date:                                                                               

 Signature of the Government servant.