Application form for grant of LTC advance

1.
Name of the Government Servant
2.
Designation
3.
Date of entering the Central Government
Service

4.
PAY + SI + NPA
5.
Whether permanent or temporary
6. Home Town as recorded in the Service Book
7.
Whether wife / husband is employed and if
so whether entitled to LTC

8.
Whether the concession is to be availed for
visiting home town and if so block for which
LTC is to be availed.

9.
(a) If the concession is to visit anywhere in
India, the place to be visited.
(b) Block for which to be availed.

10.
Single rail fare/bus fare from the
headquarters to home town/place of visit by
shortest route.

Persons in respect of whom LTC is proposed to be availed.
S.No Name Age Relationship
1.
2.
3.
4.
5.
11.
6.
12.
Amount of advance required.

Rs.

I declare that the particulars furnished above are true and correct to the best of my knowledge. I
undertake to produce the tickets for the outward journey within ten days of receipt of the advance.

In the event of cancellation of the journey or if I fail to produce the tickets within ten days of receipt of
advance, I undertake to refund the entire advance in one lump sum.


Date
Signature of Government Servant.


G.A.R. 14-C
Sub Bill No._________

LEAVE TRAVEL CONCESSION BILL FOR THE BLOCK OF YEAR_____________TO_____

Note:-- This bill should be prepared in duplicateone for payment and the other as office copy.

PART A (To be filled up by Government Servant)

1. Name of the Government Servant
2. Designation
3. PAY + SI + NPA
4. Headquarters
5. Nature and period of leave sanctioned

From To
Particulars of members of family in respect of whom the L.T.C. has been claimed.
S.
No.
Name (s) Age Relationship with the Government
Servant
1.
2.
3.
4.
5.
6.
6.



7. Details of journey (s) performed by Government servant and the members of his/her family.
Departure Arrival
Date &
Time
From
Date &
Time
To
Distance
in Kms
Mode of Travel
& class of
accommodation
used
No of
fares
Fair
paid
Remarks









8. Amount of advance, if any, drawn Rs.
9. Particulars of journey (s) for which higher class of accommodation than the one to which the Government
servant is entitled was used. (Sanction No. & Date to be given.)
Place Fare paid
From To
Mode of
conveyance
Class to which
entitled.
Class by
which
actually
travelled
No of
Fares
Rs. P.





10. Particulars of journey (s) performed by road between places connected by rail
Nature of Place Rail fare
From To
Class to which
entitled Rs. P.





Certified that the:-
1. Information, as given above is true to the best of my knowledge and belief; and
2. 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 by him/her separately or himself/herself
or for any of the family members of the concerned block of _____________Years.

Date_______________________

Signature of Government Servant

Part B ( to be filled in the Bill Section )

1. The net entitlement on account of leave travel concession works out to Rs._______________________ as
detailed below:-
(a) Railway/Air/Bus/Steamer fare Rs._______________________________
(b) Less amount of advance drawan vide
Voucher No______________dated__________ Rs._______________________________
________________________________________
Net Amount Rs.
________________________________________



2. The expenditure is debitable to

Initial of Bill Clerk Signature of Drawing & Disbursing Officer




Counter signed
Signature of Controlling Officer
Certified that necessary entries have been made in the Service Book of
Shri/Shrimati/Miss______________________



Signature of the officer authorized to attest
entries in the Service Book.


Passed for Rs..Rupees..
..




Signature of Controlling Officer



FOR USE IN ACCOUNTS BRANCH / PAY AND ACCOUNTS OFFICE

VOUCHER NODATED

Pay Rs..Rupees
Vide Cheque No.dated..




Signature of the Drawing and Disbursing Officer



LTC CERTIFICATE
CERTIFICATES TO BE GIVEN BY THE CONTROLLING OFFICER

Certified :

(i) that Shri/Shrimati/Kumari (Name of the Govt. Servant)
Has rendered continuous service for one year or more on the date of commencing the outward journey.

(ii) that necessary entries as required under para 3 of the Ministry of Home Affairs O.M. No.43/1/55-Ests.(A)
Part II dated 11
th
October, 1956 have made in the Service book of Shri/Shrimati/Kumari




Signature & Designation of the Controlling Officer





CERTIFICAT TO BE GIVEN BY THE GOVT. SERVANT

1. I have not submitted any other claim so for Leave Travel Concession in respect of myself or my
family members in r/o the block of the yearsand

2. I have already drawn TA for the Leave Travel Concession in respect of journey performed by
me/my wife with..children. The claim is in respect to 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 TA 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 with..children/children
none of whom availed of the concession relating to that block.

4. I have already drawn TA for the Leave Travel Concession in r/o a journey performed by me in
the yearin r/o of block of two
yearsand.. This claim is in r/o of the journey performed by me
in the year..This is against the concession admissible once every year
in a prescribed block for visiting home town as all the members of my family are living away
from place of work.

5. The journey has been performed by me/my
wife..children/..children to the declare home town
viz

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

That my husband/wife is employed in Government Service and the concession has not been
availed of by him/her separately for himself/herself or for any of the family members 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 from 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 owned by the
Central Government Local Body which provides L.T.C facilities to its employees and their
families.




Signature of Government Servant
CONVEYANCE HIRE CLAIM

1. Name of the Government Servant
2. Designation
3. Officer / Section to which attached
4. Department Name
10. Particulars of journey for which conveyance is claimed.
Date of Journey &
time
Particulars
Date Time From To
Mode of
conveyance
Distance
in Kms
Purpose of
Journey
Amount
Spent in
Rs.
1 2 3 4 5 6 7 8
































Note:- In case of Taxi / Scooter hire the Registration No of the vehicle should be quoted and fare receipt be
enclosed.

Date____________ Signature of the Claimant___________________________________

Name and Designation of the Claimant_________________________

G.A.R. 14 -- A
Sub Bill No._________________
TRAVELLING ALLOWANCE BILL FOR TOUR
Note: - This bill should be prepared in duplicate one for payment and the other as office copy

PART A ( To be filled up by Government Servant )

1. Name of the Government Servant
2. Designation
3. PAY + S! + NPA
4. Headquarters
5. Details and purpose of journey (s) performed.
Departure Arrival Fair paid Duration
of Halt
Date 8 Time From Date 8
Time
To
Node of Travel
8 class of
accommodation
used
Distance
in Kms for
road
mileage

Purpose of
Journey
1 2 3 4 5 6 7 S 9








Node of journey:
(i)

Air
(a) Exchange voucher arranged by office
(b) Ticket fExchange voucher arranged by

YesfNo
(ii) Rail
(a) Whether traveled by mail fexpressfordinary train?
(b) Whether return tickets available?
(c) !f available, whether return tickets purchased? !f not, state reasons

YesfNo
6.
(iii) Road
Node of conveyance used, i.e. by Government transportfby taking a
taxi, a single seat in a bus or other public conveyancefby sharing with
another Government servant in a car belonging to him or to a third per
to be specified.

7. Dates of absence from place of halt on account of
(a) R.H. and C.L.
(b) Not being actually in camp on Sundays and holidays.



S. Dates on which free board and for lodging provided by the State or any
organization financed by State funds:
(a) Board Only
(b) Lodging only
(c) Board and lodging.



9. Particulars to be furnished along with hotel receipts, etc., in cases where higher rate of D.A. is claimed for stay
in hotel f other establishments providing board and f or lodging at scheduled tariffs.
Period of Stay S.No
From To
Name of the hotel Daily rate of lodging
charged in Rs.
Total amount
Paid Rs.
1.
2.
3.
4.
5.
10. Particulars of journey(s) for which higher class of accommodation than the one to which the Government
servant is entitled was used.
Name of places S.No

1

Date

2
From
3
To
+
Node of
conveyance
used
5
Class to
which
entitled
6
Class by
which
travelled
7
Fare of the
entitled class
Rs. P.
8
1.

2.

3.

4.

5.

!f the journey(s) by higher class of accommodation has been
performed with the approval of competent authority, No and
date of the sanction may be quoted.



11. Details of journey (s) performed by road between places connected by rail.
Nature of Place Rail fare S.No Date
From To Rs. P.
1 2 3 4 5



12. Amount of T.A. advance, if any, drawn Rs.
Certified that the information, as given above, is true to the best of my knowledge and belief.

( )
Signature of the Government Servant
Date____________________________
Part - B { to be filled in the Bill Section )

1. The net entitlement on account of Travelling Allowance works out to Rs._____________________________
as detailed below:-

(a) RailwayfAirfBusfSteamer fare Rs._______________________________

(b) Road Nileage for ___________________Kms.

@______________________perfkms

(c) Daily allowance
(i) ___________________days @ Rs____________per day.
(ii) ___________________days @ Rs____________per day.
(iii)___________________days @ Rs____________per day.
Rs._______________________________

(d) Actual expenses Rs._______________________________
Gross amount Rs._______________________________

(e) Less amount of T.A.advance, if any, drawan vide
voucher No______________dated__________ Rs.__________________________________
________________________________________
Net Amount Rs.
________________________________________



2. The expenditure is debitable to



Initial of Bill Clerk Signature of Drawing & Disbursing Officer




Counter signed



Signature of the Controlling Officer










CERTIFICATES

1. Certified that I/my family was neither allowed free transit by Rail under free pass or otherwise provided with
means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in
this bill.

2. Certified that I/my family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the
establishment.

4. Certified that the journey on .was performed by Mail/Express train in the interest public
service.

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily
allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at.from
. to while on inspection duty
continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the
higher rates rule 46 of Supplementary rule by taking a single seat in a taxi/motor or mini bus or lorry playing
for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed in
Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.
The number of kilometers actually traveled by road being.

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me
on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum
claimed in the bill.

14. Certified that I have transportedkgms. of
luggage on my transfer from.to..



Signature of the claimant

Counter singed

( Signature 8 Designation of the Controlling Officer)
G.A.R. 14 -- B
[ See Rule 66 (1) & 90 (1), (I) ]

Sub Bill No._________________

TRAVELLING ALLOWANCE BILL FOR TRANSFER
Note: - This bill should be prepared in duplicate one for payment and the other as office copy

PART A ( To be filled up by Government Servant )

1. Name
2. Designation 8 Office
3. PAY at the time of transfer Rs.
(a) Old



4. Headquarters
(b) New
(a) Old




5. Residential Address
(b) New


Particulars of the members of the family as on the date of transfer [vide S.R.2 (8) | :
S.No Name Age Relationship
1. 2 3 +
1.
2.
3.
4.
11.
5.
5. Details of journey(s) performed by the Government servant as well as members of hisfher family.
Departure Arrival
Date 8 Time From Date 8 Time To
Node of Travel
8 class of
accommodation
used
No of
fares
Fare paid
Rs.
Distance in
Kms for road
1 2 3 4 5 6 7 S








6. Transportation charges for personal effect (Noney Receipts to be attached.
Station Date Node of
transport
From To
Weight
in Kgs.
Rate
Rs.
Amount
Rs.
Remarks
1 2 3 + 5 6 7 8






7. Transportation charges for personal conveyance (Noney receipt to be attached)
(a) Node of transport and station to which transported.

(b) Amount. Rs.
S. Amount of T.A. advance, if any, drawn Rs.
9. Particulars of journey(s) for which higher class of accommodation than the one to which the Government servant
is entitled was used.
Name of places S.
No

1
Date


2
From
3
To
+
Node of
conveyance
used
5
Class to
which
entitled
6
Class by
which
travelled
7
Fare of the
entitled class
Rs. P.
8
1.

2.

3.

4.

5.

!f the journey(s) by higher class of accommodation has been
performed with the approval of competent authority, No and
date of the sanction may be quoted.



11. Details of journey (s) performed by road between places connected by rail.
Nature of Place Rail fare S.No Date
From To Rs. P.
1 2 3 4 5




Certified that the information, as given above, is true to the best of my knowledge and belief.



( )
Date______________________ Signature of the Government Servant
Place______________________ Name___________________________

Part - B { to be filled in the Bill Section )

1. The net entitlement on account of Travelling Allowance works out to Rs._______________________________

(Rupees___________________________________________________________________________________

as detailed below:-

(a) RailwayfAirfBusfSteamer fare Rs._______________________________

(b) Road Nileage for ___________________Kms.

@______________________perfkms

(c) Composite transfer grant Rs.__________________

(d) Transportation of personal effects Rs.________________

(e) Transportation of private conveyance Rs.______________

(f) Gross amount ( (a) + (b) + (c) + (d) + (e) ) Rs.__________________________________

(g) Less amount of advance(s), if any, drawan vide
voucher No______________dated__________ Rs.__________________________________
________________________________________
Net Amount{ f-G) Rs.
________________________________________



2. The expenditure is debitable to



Initial of Bill Clerk Signature of Drawing & Disbursing Officer




Counter signed



Signature of the Controlling Officer








CERTIFICATES

1. Certified that I/my family was neither allowed free transit by Rail under free pass or otherwise provided with
means of communication at expense of the state or Local Bodies journey for which T.A. has been claimed in
this bill.

2. Certified that I/my family actually traveled by the class for which T.A. has been claimed in this bill.

3. Certified that the number of kilometers shown in the bill is in accordance with the poly maternal tables of the
establishment.

4. Certified that the journey on .was performed by Mail/Express train in the interest public
service.

5. Certified that I was actually not merely constructively in camp on Sundays and holidays for which daily
allowance is claimed.

6. Certified that I was not absent on Casual Leave during the period for which daily allowance has been claimed.

7. Certified during my halt at.from
. to while on inspection duty
continue to incur expenditure after the first 10 days.

8. Certified that I did not perform the road journey for which the kilometer allowance has been claimed at the
higher rates rule 46 of Supplementary rule by taking a single seat in a taxi/motor or mini bus or lorry playing
for hire.

9. Certified that I incurred running expenses in a car for which claimed in this bill for journey.

10. Certified that the road journeys for which kilometer has been claimed at the higher prescribed in
Supplementary rule 46 was performed by my own car.

11. Certified that the road journeys for which mileage is claimed were performed by road but were charged by rail.
The number of kilometers actually traveled by road being.

12. Certified that the family members for whom T.A. has been claimed actually travelled with me or followed me
on transfer. They were wholly dependent upon me & residing with me.

13. Certified that actual expenses incurred as cost or transportation of personal effects were not less than the sum
claimed in the bill.

14. Certified that I have transportedkgms. of
luggage on my transfer from.to..



Signature of the claimant

Counter singed

( Signature 8 Designation of the Controlling Officer)

Performa for application for advance from Provident Funds
Application for Advance from G.P.F.

1. Name of the Subscriber


2. Account Number


3. Designation


4. Pay

Rs.
Balance at Credit of the subscriber on the date of application as below:-
i Closing balance as per statement for the
year___________

Rs
ii Credit from _________to___________on
account of monthly subscription.

Rs
iii Refunds

Rs
iv Withdrawals during the period from
__________to_____________

Rs
5.
v Net balance at credit Rs
6. Amount of advance/outstanding, if any, and the

7. Amount of Advance required
a. Purpose for which the advance is required


b Rules under which the request is covered


If advance is sought for House Building etc., following information may be given:-
i Location & measurement of the plot


ii Whether plot is freehold or on lease


iii Plan for construction


iv If the flat or plot being purchased is
from a H.B. Society, the name of
Society, the location &
measurement, etc.

v Cost of construction
c
vi If the purchase of flat is from DDA
or any Housing Board etc., the
location, dimension, etc., may be
given.

8.
d If advance is required for education of children, following details may be given:-
i Name of the son / daughter


ii Class & Institution / College where
studying



iii Whether a day-scholar or a hostler


If advance is required for treatment of ailing family members, following details may
be given:-
i Name of the patient and
relationship


ii Name of the Hospital / Dispensary
/Doctor where the patient is
undergoing treatment.


iii Whether outdoor / indoor patient



e
iv Whether reimbursement available
or not

9 Amount of the consolidated advance (Items 6
and 7 ) and number of monthly installments in
which the consolidated advance is proposed to
be repaid.


Rs.__________________in ________
Installments.

10
.
Full Particulars of pecuniary circumstances of
the subscriber, justifying the application for the
advance



I certify that particulars given below are correct and complete to the best of my
knowledge and belief and that nothing has been concealed by me.


Date:-
Signature of the Applicant
Name___________________________
Designation______________________
Section / Branch__________________


Note:- In case of advance under 8 to 8 (e), no certificate or documentary evidence would be required.



APPLICATION FOR WITHDRAWAL FROM G.P.F.
1. Name of the Subscriber
2. Account Number
3. Designation
4. Pay Rs.
5. Date of Joining service and date of
Superannuation

Balance at Credit of the subscriber on the date of application as below:-
i Closing balance as per statement for the
year___________
Rs
ii Credit from _________to___________on
account of monthly subscription.
Rs
iii Refunds made to the Fund after the closing
balance , vide (i) above
Rs
iv Withdrawals during the period from
__________to_____________
Rs
5.
v Net balance at credit on date of application Rs
6. Amount of Withdrawal required
a. Purpose for which the withdrawal is
required
8.
b Rules under which the request is covered
9 Whether any withdrawal was taken for the same
purpose earlier. If so, indicate the amount and the
year.
.
10
.
Name of the PAO maintaining the Provident Fund
Account
Date:-
Signature of the Applicant
Name___________________________
Designation______________________
Section / Branch__________________
Annexure-D
Forms
1
Form of Application for Final Payment/Transfer to Corporate Bodies/Other
Governments of Balances in the
General Provident Fund Account

To

The Pay and Accounts Officer,
_________________________,
_________________________,
(Through the Head of Office)

Sir,

I am to retire/have retired have proceeded on leave preparatory to retirement for
_________________________months/have been discharged/dismissed/have been
permanently transferred to ________________________ / have resigned finally from
Government service/have resigned service under ___________________ Government to
take up appointment with ___________ and my resignation has been accepted with effect
from _________________forenoon/afternoon. I joined service with______________
on______________forenoon/afternoon.

2. My Provident Fund Account No. is __________________________

3. I desire to receive payment through my office through the
____________________Treasury/Sub Treasury. Particulars of my personal marks of
identification left hand thumb and finger impressions ( in the case of illiterate subscribers
and specimen signature ( in case of literate subscribers) in duplicate, duly attested by a
Gazetted Officer of the Government, are enclosed.


PART-I
[To be filled in when the application for final payment
is submitted up to one year prior to retirement]

4. I request that the amount of Rs.________________ standing to the credit in my
Provident Fund Account as indicated in the Accounts Statement issued to me for the yar
___________________(enclosed) / as appearing in my ledger account being maintained
by you_____________________________ Treasury/Sub Treasury/Head of Office, my
please be arranged to be paid to me as first installment of final payment.

5. * * * * * *



6. After payment of the first installment of my Provident Fund balance, I will apply
for the payment of subsequent installments in Part-II of the form immediately on
retirement.


Yours faithfully


Signature-------------------------------
Station------------- Name________________________
Date:-___________ Address_____________________
This applies only when payment is not desired through the Head of Office.

( FOR USE BY HEADS OF OFFICES )

Forwarded to the Pay & Accounts Officer_________________________ for
necessary action.

2. The Provident Fund Account No.__________________ of Shri/Shrimati/Kumari
(as certified from the Statements furnished to him/ her from year to year ) is
____________________________.

3. He/She is due to retire from Government Service
on________________________________________________________.

4. Certified that he/she had taken the following advances in respect of
which______________________instalment of Rs._____________________are yet to be
recovered and credited to the Fund Account. The details of the final withdrawals granted
to him/her are also indicated below:-

Temporary Advances Final Withdrawals

1._________________________ ___________________________
2. _________________________ ___________________________
3. _________________________ ___________________________
4. _________________________ ___________________________

5. * * * * * *


Signature
of the Head of Office


PART-II
[To be submitted by the Subscriber immediately after his/her retirement.
This Part is also applicable in the case of subscribers who apply for final payment for the
first time after the date of superannuation, discharge, resignation etc. ]

In continuation of my earlier application, dated___________________________,
for the final payment of Provident Fund balances, I request that the entire balance at my
credit with interest due under the rules may be paid to me.
Or
I request that the entire amount at my credit with interest due under the rules may
be paid to me /transferred to ____________________________________.


Signature-------------------------------
Name________________________
Address_______________________
( FOR USE BY HEADS OF OFFICES )

Forwarded to the Pay & Accounts Officer_________________________ for
necessary action/in continuation of Endorsement No. _____________ dated__________.

2. He/She has finally retired/ will proceed on leave preparatory to retirement for
_________________________months/have been discharged/dismissed/have been
permanently transferred to ________________________ / have resigned finally from
Government service/have resigned service under ___________________ Government to
take up appointment with ___________ and my resignation has been accepted with effect
from _________________forenoon/afternoon. He/She joined service
with______________ on______________forenoon/afternoon.

3. The last fund deduction was made from his/her pay in this office bill
No._______________, dated______________, for Rs.______________
(Rupees___________________________), cash voucher No._______________ of
__________________Treasury, the amount of deduction being Rs._________________
and recovery on account of refund of advance Rs.___________________.

4. Certified that he/she was neither sanctioned any tempory advance nor any final
withdrawal from his/her Provident Fund Account during the 12 months immediately
preceding the date of his /her quitting service under
_______________________Government/proceeding on leave preparatory to retirement
or thereafter

or

Certified that the following temporary advances/final withdrawals were
sanctioned to him/her and drawn from his/her Provident Fund Account during the 12
months immediately preceding the date of his/her quitting service
under_________________________ Government/proceeding on leave preparatory to
retirement or thereafter

Amount of Advance/withdrawal Date Voucher number

1._________________________ ___________________________
2. _________________________ ___________________________
3. _________________________ ___________________________
4. _________________________ ___________________________

5. * * * * * *

6. It is certified that no demands/following demands of Government are due for
recovery
1
.

7. Certified that he/she has not resigned from Government service with prior
permission of the Central Government to take up an appointment in an other Department
of the Central Government or under a State Government or under a body corporate
owned or controlled by the State
2
.



Signature
Of the Head of Office/Department















1. Certificate No.6 to be furnished in the case of Contributory Provident Fund Only.
2. Please score out if not necessary.


FORM OF APPLICATIONS FOR MEDICAL CLAIMS
MED.9?
Forn of alicaiion for claining rcfund of ncdical ccnscs incurrcd in conncciion wiiI ncdical aiicndancc
and/or ircaincni for Ccniral Covcrnncni scrvanis and iIcir fanilics - for ncdical aiicndancc/ircaincni
ialcn loiI fron iIc AuiIoriscd Mcdical Aiicndani and a Hosiial
1. Nanc and dcsignaiion of Covcrnncni scrvani (in llocl lciicrs} .
i} WIciIcr narricd or unnarricd . .
ii} If narricd, iIc lacc wIcrc wifc/Iusland is Enloycd .
2. Officc in wIicI cnloycd .
3. Pay of iIc Covcrnncni scrvani as dcfincd in iIc Fundancnial Fulcs, and any
oiIcr cnoluncnis wIicI sIould lc sIown scaraicly
.
4. Placc of duiy .
5. Aciual rcsidcniial addrcss .
6. Nanc of iIc aiicni and Iis/Icr rclaiionsIi io iIc Covcrnncni scrvani. N.D.
- In iIc casc of cIildrcn siaic agc also
.
7. Placc ai wIicI iIc aiicni fcll ill .
8. Dciails of iIc anouni claincd .
I. Mcdical Aiicndancc -
i} Fccs for consuliaiion indicaiing -
a} TIc nanc and dcsignaiion of iIc Mcdical Officcr consulicd and iIc Iosiial or
discnsary io wIicI aiiacIcd
l} TIc nunlcr and daics of consuliaiion and iIc fcc aid for cacI consuliaiion.
c} TIc nunlcr and daics of injcciion and iIc fcc aid for cacI injcciion.
d} WIciIcr consuliaiions and/or injcciions wcrc Iad ai iIc Iosiial, ai iIc consuliing
roon of iIc ncdical officcr or ai iIc rcsidcncc of iIc aiicni.
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ii} CIargcs for aiIological, lacicriological, radiological, or oiIcr sinilar icsis
undcrialcn during diagnosis indicaiing-
a} TIc nanc of iIc Iosiial or laloraiory wIcrc undcrialcn; and
l} WIciIcr iIc icsis wcrc undcrialcn on iIc advicc of iIc auiIorizcd ncdical
aiicndani. If so, a ccriificaic io iIai cffcci sIould lc aiiacIcd.


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.
iii} Cosi of ncdicincs urcIascd fron iIc narlci
(CasI ncnos and iIc csscniialiiy ccriificaic sIould lc aiiacIcd}.
.
II HospItaI Treatment.
Nanc of iIc Iosiial
CIargcs for Iosiial ircaincni, indicaiing scaraicly iIc cIargcs for -
i} Acconnodaiion (Siaic wIciIcr ii was according io iIc siaius or ay of iIc
Covcrnncni scrvani and in cascs wIcrc iIc acconnodaiion is IigIcr iIan iIc siaius
of iIc Covcrnncni scrvani, a ccriificaic sIould lc aiiacIcd io iIc cffcci iIai iIc
acconnodaiion io wIicI Ic was cniiilcd was noi availallc}
ii} Dici
iii} Surgical ocraiion or ncdical ircaincni or confincncni.
iv}PaiIological, lacicriological, radiological or oiIcr sinilar icsis indicaiing -
a} TIc nanc of iIc Iosiial or laloraiory ai wIicI undcrialcn, and
l} WIciIcr undcrialcn on iIc advicc of iIc . ncdical officcr in cIargc of iIc casc ai
iIc Iosiial. If so, a ccriificaic io iIai cffcci sIould lc aiiacIcd.
v} Mcdicincs.
vi} Sccial ncdicincs (CasI ncnos and iIc csscniialiiy ccriificaics sIould lc
aiiacIcd}
vii} Ordinary nursing
viii} Sccial nursing, i.c., nurscs, sccially cngagcd for iIc aiicni. Siaic wIciIcr iIcy
arc cnloycd on iIc advicc of iIc ncdical officcr in cIargc of iIc casc ai iIc Iosiial
or ai iIc rcqucsi of iIc Covi. Scrvani or aiicni. In iIc forncr casc a ccriificaic fron
iIc ncdical officcr in cIargc of iIc casc and counicrsigncd ly iIc Mcdical
Sucrinicndcni of iIc Iosiial sIould lc aiiacIcd.
i} Anlulancc cIargcs (Siaic iIc journcy - io and fron- undcrialcn}

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NOTE 1. - If iIc ircaincni was rcccivcd ly iIc Covi. scrvani ai Iis rcsidcncc undcr Fulc 7 of iIc C.S. (M.A}
Fulcs, 1944 givc ariiculars of sucI ircaincni and aiiacIcd a ccriificaic fron iIc auiIorizcd ncdical
aiicndani as rcquircd ly iIcsc rulcs.
NOTE 2. - If iIc ircaincni was rcccivcd ai a Iosiial oiIcr iIan a Covi. Iosiial, ncccssary dciails and iIc
ccriificaic of iIc auiIorizcd ncdical aiicndani iIai iIc rcquisiic ircaincni was noi availallc in iIc ncarcsi
Covi. Iosiial sIould lc furnisIcd.
III. Consuliaiion wiiI Sccialisi - Fccs aid io a sccialisi or a Mcdical Officcr oiIcr
iIan iIc auiIorizcd ncdical aiicndani, indicaiing
a} TIc nanc and dcsignaiion of iIc Sccialisi or Mcdical Officcr consulicd and iIc
Iosiial io wIicI aiiacIcd.
l} Nunlcr and daics of consuliaiions and iIc fccs cIargcd for cacI consuliaiion.
c} wIcrcvcr consuliaiion was Iad ai iIc Iosiial, ai iIc consuliing roon of iIc
Sccialisi or Mcdical Officcr, or ai iIc rcsidcncc of iIc aiicni, and
d} WIciIcr iIc Sccialisi or Mcdical Officcr was consulicd on iIc advicc of iIc
auiIorizcd ncdical aiicndani and iIc rior aroval of iIc CIicf Adninisiraiivc
Mcdical Officcr of iIc Siaic was oliaincd. If so, a ccriificaic io Iai cffcci sIould lc
aiiacIcd.



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9. Toial anouni claincd .
10. Lcss advancc ialcn on .
11. Lisi of cnclosurc .
DECLAFATION TO DE SICNED DY THE COVEFNMENT SEFVANT
I Icrcly dcclarc iIai iIc siaicncni in iIc alicaiion arc iruc io iIc lcsi of ny lnowlcdgc and lclicf and
iIai iIc crson for wIon ncdical ccnscs wcrc incurrcd is wIolly dccndcni uon nc.

Daicd................. Signaiurc of iIc Covcrnncni scrvani
and Officc io wIicI aiiacIcd.
ESSENTIALITY CERTIFICATE
CERTIFICATE'A'
(To be compIeted In tbe case oI patIents wbo are not admItted to bospItaI Ior treatment)
Ccriificaic granicd io Mrs./Mr./Miss.................... Wifc/ Son/ DaugIicr of
MF/MFS/MISS ..................................... cnloycd in iIc ........ ...... ..... ......................
I, Dr. .................................... Icrcly ccriify.-
(a} iIai I cIargcd and rcccivcd Fs. ......... for ........ consuliaiions on ................ (daics io lc
givcn} ai ny consuliing roon/ ai iIc rcsidcncc of iIc aiicni;
(l} iIai I cIargcd and rcccivcd Fs............ for adninisicring ..... inira-vcnous/inira-
nuscular/sulcuiancous injcciions on........(daics io lc givcn} ai....................... ny consuliing
Foon/iIc rcsidcncc of iIc aiicni;
(c} iIai iIc injcciions adninisicrcd wcrc noi/wcrc for innunising or roIylaciic uroscs;
(d} iIai iIc aiicni Ias lccn undcr ircaincni ai .... ...................... Iosiial/ ny consuliing roon and
iIai iIc undcrncniioncd ncdicincs rcscrilcd ly nc in iIis conncciion wcrc csscniial for iIc rccovcry/
rcvcniion of scrious dcicrioraiion in iIc condiiion of iIc aiicni. TIc ncdicincs arc noi sioclcd in iIc
.................................. (nanc of iIc Iosiial} for suly io rivaic aiicnis and do noi includc
roriciary rcaraiions for wIicI cIcacr sulsianccs of cqual iIcracuiic valuc arc availallc nor
rcaraiions wIicI arc rinarily food, ioilcis or disinfccianis.
Name oI MedIcInes PrIce
1 ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
2. ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
3. ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
4. ........ ........ ........ ........ ........ ........ ........ ........ ........ ........
(c} iIai iIc aiicni is/was suffcring fron ..................... and
is/was undcr ny ircaincni fron ................ io .................;
(f} iIai iIc aiicni is/was noi givcn rc-naial or osi-naial ircaincni;
(g} iIai iIc X-ray laloraiory icsi, cic., for wIicI an ccndiiurc of Fs. ..... was incurrcd was ncccssary
and wcrc undcrialcn on ny advicc ai .......... (nanc of iIc Iosiial or laloraiory};
(I} iIai I rcfcrrcd iIc aiicni io Dr. ........................ for SPECIALIST consuliaiion and iIai iIc
ncccssary aroval of iIc ........................ (Nanc of iIc CIicf Adninisiraiivc Officcr of iIc Siaic} as
rcquircd undcr iIc rulcs was oliaincd;
(i} iIai iIc aiicni did noi rcquirc/rcquircd Iosiialisaiion.


Sgnutuc o AMA/Dcsgnuton o tIc Mcdcu occ und
Dutcd.----------- Iostu/ dscnsu to uIcI uttucIcd.
N.D..-ccriificaics noi alicallc sIould lc sirucl off. Ccriificaic (c} is conulsory and nusi lc fillcd in ly iIc
ncdical officcr in all cascs.
ESSENTIALITY CERTIFICATE
CERTIFICATE-B
(To lc conlcicd in iIc casc of aiicnis WHO AFE ADMITTED io Hosiial for ircaincni}

Ccriificaic granicd io Mrs./Mr./Miss ................................ wifc /son/daugIicr of Mr./ Mrs./ Miss
................................. cnloycd ................................. .................................

PART-A
I, Dr. .................................. Icrcly ccriify .-

(a} iIai iIc aiicni was adniiicd io Iosiial on iIc advicc of ............................ (nanc of iIc ncdical
officcr}/on ny advicc;
(l} iIai iIc aiicni Ias lccn undcr ircaincni ai ......... and iIai iIc undcrncniioncd ncdicincs rcscrilcd
ly nc in iIis conncciion wcrc csscniial for iIc rccovcry/rcvcniion of scrious dcicrioraiion in iIc
condiiion of iIc aiicni. TIc ncdicincs arc noi sioclcd in iIc .................... .................................
(nanc of iIc Iosiial} for suly io rivaic aiicnis and do noi includc roriciary rcaraiions for
wIicI cIcacr sulsianccs of cqual iIcracuiic valuc arc availallc noi rcaraiions wIicI arc rinarily
foods, ioilcis or disinfccianis.


NAME OF MEDICINES PFICE

1. ................................. ................................. .................................

2. ................................. ................................. .................................

3. ................................. ................................. .................................

4. ................................. ................................. .................................

5. ................................. ................................. .................................


(c} iIai iIc injcciions adninisicrcd wcrc/wcrc noi for innunising of roIylaciic uroscs;
(d} iIai iIc aiicni is/was suffcring fron ......................... and is/was undcr ircaincni fron .................. io
...................;
(c} iIai iIc X-ray, laloraiory icsi cic. for wIicI an ccndiiurc of Fs............ was incurrcd wcrc ncccssary
and wcrc undcrialcn on ny advicc ai ........................ (nanc of Iosiial or laloraiory};
(f} iIai I callcd on Dr. ............................... for sccialisi consuliaiion and iIai iIc ncccssary aroval of
iIc ................ (nanc of iIc CIicf Adninisiraiivc Mcdical Officcr of iIc Siaic} as rcquircd undcr iIc
rulcs, was oliaincd.

Signaiurc and Dcsignaiion of iIc
Mcdical Officcr-in-cIargc of iIc casc ai iIc Iosiial.
PART B
ccriify iIai iIc aiicni Ias lccn undcr ircaincni ai iIc ....................... Iosiial and iIai iIc scrvicc of iIc
sccial nurscs for wIicI an ccndiiurc of Fs.......... was incurrcd, vidc lills and rccciis aiiacIcd, wcrc
csscniial for iIc rccovcry/rcvcniion of scrious dcicrioraiion in iIc condiiion of iIc aiicni.

Signaiurc of iIc Mcdical Officcr-in-cIargc
of iIc casc ai iIc Iosiial.

COUNTERSIGNED
I ccriify iIai iIc aiicni Ias lccn undcr ircaincni ai iIc ........................ Iosiial and iIai iIc faciliiics
rovidcd wcrc iIc nininun wIicI wcrc csscniial for iIc aiicni's ircaincni.


Mcdical Sucrinicndcni
Placc .................. . .....................Hosiial

NOTE.- CEFTIFICATES NOT APPLICADLE SHOULD DE STFUCK OFF. CEFTIFICATE (D}
IS COMPULSOFY AND MUST DE FILLED IN DY THE MEDICAL OFFICEF IN ALL CASES.