A Compilation of Blank Forms used in

Central Government Departments.

-trj-
Sub Bill No.______________ No. 02

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 by the Government Servant]

1. Name of Officer / Official

2. Designation
3. Pay Rs.
4. Head Quarter
5. Details and Purpose of Journey(s) performed As under

Departure Arrival Mode of travel Fare Distance

Date & From Date & To & Class of Paid in Kms.
Time Time Accommodation Rs.
1. 2. 3. 4. 5. 6. 7.

Purpose of Journey
Performed
6. Mode of Journey
(i) Air
(a) Exchange voucher arranged by office Yes / No
(b) Ticket / Exchange voucher arranged by
(ii) Rail
(a) Whether travelled by Mail / Express / Ordinary Yes / No
Train ?
(b) Whether return tickets available ? Yes / No
(c) If available whether return tickets purchased ? Yes / No
If not state reasons.
(iii) Road
Mode of conveyance used i.e. by Government transport, by
taking a Taxi, a single seat in a bus or other public con-
veyance, by sharing with another Government Servant in a
car belonging to him/her or to a third person to be specified

7. Dates of absence from Place of halt, on account of :

(a) Restricted Holiday & Casual Leave
(b) Not being actually in camp on Sundays and Holidays

8. Dates on which free Boarding and / or Lodging by the State or any organization financed by State
Funds :
(a) Boarding only
(b) Lodging only
(c) Boarding 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/other establishments providing board and/or lodging at scheduled tariffs :
Period of Stay Name of the Hotel Daily rate of Total Amount
From To lodging Paid
charge
10. Particulars of journey(s) for which higher class of accommodation than the one which the
Government servant is entitled was used :
Date Name of Place Mode of Class to Class by Fare of the
From To Conveyance which which entitled
used entitled travelled class
1 2 3 4 5 6 7
Rs. Ps.

Total
If the journey by higher class of accommodation has
been performed with the approval of the Competent
Authority, No. and date of the sanction may be quoted.

11. Details of Journey(s) performed by road between places connected by Rail :

Date Name of Place Fare Paid
From To
1 2 3 Rs. Ps.

Total

12. Amount of Advance of Travelling Allowance, if any, drawn Rs.

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

[ ]
Date : ______________ Signature of the Government Servant
 PART – B
[ To be filled in the Bill Section ]
The net entitlement on account of Travelling Allowance works out to Rs. ________________ as
detailed below : (Amount in Rs.)
(a) Railway / Air / Bus / Steamer Fare
(b) Road mileage for ______________kms @ ______________ per km.

(c) Daily Allowance

Date Time Hrs./Min. Stay / Rate of
From To Journey D.A.

(d) Actual Expenses :

Auto/Taxi/Other

(e) Gross Amount

(f) Less : Amount of T.A. Advance if any drawn vide Voucher No.
__________________dated ________________.

(g) Net Amount

The Expenditure is debitable to T. A. Account.

Remarks :

Signature of Drawing & Disbursing Officer

Passed for Payment of Rs. ____________ only.

Signature of the Controlling Officer

Sub Bill No.______________ No. 03

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 by the Government Servant]

1. Name of Officer / Official

2. Designation
3. Pay at the time of transfer Rs.
4. Head Quarter Old
New
5. Residential Address
Old Address

New Address

6. Particulars of the members of the family as on the date of transfer :

Sr. No. Name of the family member Age Relationship with the Govt. Servant

7. Details of Journey(s) performed by Government servant as well as members of his/her family :

Departure Arrival Mode of No. of Fare Paid Distance
Date & From Date & To travel & fares in Kms
Time Time Class by Road
8. Transportation charges of personal effects (Money receipts to be attached) :
Date Mode STATION Weight in Rate Amount Remarks
From To Kgs.

9. Transportation charges of personal conveyance ( Money receipt to be attached ) :

a. Mode of Transport and Station to which transported

b. Amount

10. Amount of advance if any drawn

11. Particulars of journey(s) for which higher class of accommodation than the one to which the
Government servant is entitled was used :
Date Name of Place Mode of Class to Class by Fare of the
From To Conveyance which which entitled class
used entitled travelled 7
1 2 3 4 5 6 Rs. Ps.

If the journey by higher class of accommodation has Total

been performed with the approval of the Competent
Authority, No. and date of the sanction may be quoted.

12. Details of journey(s) performed by Road between places connected by Rail :

Date Name of Places Fare Paid
From To

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

[ ]
Date : ______________ Signature of the Government Servant
 PART – B
[ To be filled in the Bill Section ]
The net entitlement on account of Travelling Allowance works out to Rs. ________________ as
detailed below : (Amount in Rs.)
(a) Railway / Air / Bus / Steamer Fare
(b) Road mileage for ______________kms @ ______________ per km.
(c) Transfer Grant
(d) Transfer Incidentals
(D.A. for ___________ day(s) @ Rs. _________ per day)
(e) Transportation of personal effects
Calculation:

(f) Transportation of private conveyance

Calculation:

Gross Amount
(g) Less amount of advance, if any drawn vide Voucher No. ____________
Dated ________________
Net Amount

The Expenditure is debitable to T. A. Account.

Remarks :

Signature of Drawing & Disbursing Officer

Passed for Payment of Rs. ____________ only.

Signature of the Controlling Officer

Form for giving intimation or seeking previous sanction under Rule 18(3) of the CCS (Conduct)
Rules, 1964 for transaction in respect of moveable property.

1. Name of the Government Servant

2. Scale of pay and present pay

3. Purpose of application/ sanction for transaction/

intimation of transaction
4. Whether the property is being acquired or
disposed off ?
5. a. Probable date of acquisition or disposal
of property.
b. If the property is already acquired/
disposed off, actual date of transaction.
6. a. Description of the property (e.g. Car/
Scooter/ Motor Cycle/ Jewellery/ Loans
etc.
b. Make, Model No. and also Registration
No., in case of vehicles where necessary.
7. Mode of acquisition/disposal (Purchase/Sale,
Gifts, mortgage lease or otherwise)
8. In case of acquisition, source or sources from
which financed/ proposed to be financed :
(a) Personal Savings
(b) Other sources giving details
9. Sale/Purchase price of the property (Market
value in the case of gifts)
10. In the case of disposal of property, was requisite
sanction/intimation obtained/given for its
acquisition ? (A copy of the sanction/
acknowledgement should be attached.)
11. a. Name and Address of the party, with
whom transaction is proposed to be
made/ has been made.
b. Is the party related to the applicant ? If
so, state the relationship.
c. Did the applicant have any dealings with
the party in his official capacity at any
time, or is the applicant likely to have
any dealing with him in the near future ?
d. Nature of official dealings with the party.
e. How was the transaction arranged ?
(Whether through any statutory body or a
private agency/ through advertisements
or through friends and relatives. Full
particulars to be given.)
12. In the case of acquisition by gifts, whether
sanction is also required under Rule 13 of the
CCS (Conduct) Rules, 1964 ?
13. Any other relevant fact which the applicant may
like to mention.
 DECLARATION

I, ___________________________________________________________ hereby declare that the

particulars given above are true. I request that I may be given permission to acquire/dispose of
property as described above from/to the party, whose name is mentioned in Item 11 above.

OR

I, ___________________________________________________________ hereby intimate the

acquisition/ disposal of property by me, detailed above. I declare that the particulars given above
are true.

Station : Signature: ___________________

Date : Designation : _________________

Note: 1. In the above form, different portions may be used according to requirement.
2. Where prior sanction is asked for, the application should be submitted at least 30 days before
the proposed date of the transaction.
T. R.-25 G.A.R.-14
[See Treasury Rule 277(1)] [See Rules 66(1) & 90(1)(1)]
Consolidated Travelling Allowance Bill of the Ministry/Department/ Office of the

_______________________________________________ for the month of _________________, _____________.

1. Bill No. and date

2. Token No. and date

3. Voucher No. & date

4. Head of account
Major Head
Minor Head
Detailed Head

5. (A) Details of T. A. Claims :

Sr. Sub-Bill Name & Designation of Govt. Gross Advance Net Remarks
No. No. Servant Claim Amount
Payable
1. 2. 3. 4. 5. 6. 7.

Total (A)

(B)
Deduct: Undisbursed travelling allowance
refunded as per details below. (A-B)
Net sum required for payment by -

1. Cheque for self Rs.

2. Cheque in favour of officers as indicated in Column No. 3 Rs.

3. Cheque/Bank Draft in favour of Rs.

Appropriation for the F. Y.
Rs.
Expenditure including this bill
Rs.

Balance Rs.
Passed for payment of Rs. ______________/- (Rupees _____________________________________________

_____________________________________________________________________ only)
Certified that the claims included in the bill have not already been paid and office copies of the sub-bills
have been suitably cancelled to avoid double payment.

Received Contents
Drawing and Disbursing Officer

6. (B) Details of undisbursed T. A. refunded

Bill No./Sub-bill No. and date Name and designation of Govt. Servant Amount (Rs.)

Total

Drawing and Disbursing Officer

For use in Pay and Accounts Office
Pre-check enfacement
Pay Order
Pay Rs. _____________/- (Rupees ______________________________________________________________________
only) to _____________________________________________(D.D.O. by designation/vide details given in the bill) by
______________ Cheque/Bank draft after disallowing Rs. _________________ (for reasons to be communicated) No. and
date of cheque delivered _________________________________________________.

J.A.O. P.A.O.
Post-check of vouchers received from cheque drawing D.D.Os. Post check of pre-checked vouchers
Admitted Rs._________________________.
Objected Rs. _________________________.
(With brief reasons)

J.A.O. P.A.O. J.A.O. P.A.O.

Note:
1. Claims for journeys on tour and transfer should be grouped and shown separately in the consolidated bill. L.T.C.
claims are to be drawn on separate bills, as these payments are chargeable to the head “Salaries”.
2. Objections, if any, on individual claims be got settled by personal contact on phone or otherwise as far as possible.
On cases where delay is anticipated, the affected claims may be ignored and the bills passed for payment in respect
of other claims found in order.
 Form T.R. 27 – A
(See Rule 281 A)
Medical charges Reimbursement bill (Non Gazetted) Establishment.
Bill No. Voucher No.

for ______________________

Detailed Medical Bill of the Establishment of the ____________________________________

___________________________________________(specify Head of Office/Department) for the

month/s of _________________________.

Head of Account : Grant No.:

Major Head :

Appropriation

Group Head
Detailed Head :

Voted Charges :
Sr. Section or Establishment and Gross Recovery Net Remarks
No. Name of the incumbent Claim of Advance Amount
Payable
1 2 3 4 5 6
 Certified that I have satisfied myself that the amount included in bills drawn 1st/2nd months/3rd
months previous to this date with the exception of those detailed below (of which the total amount has
been refunded by deduction from this bill) have been disbursed to the Government servants therein
named and their receipts taken in the office copy of the bill or in a separate acquaintance roll.

Details of Medical Charges refunded

Section of establishment and name of Period Amount
incumbent From To

Appropriation for the year

_______________. Rs.
Expenditure (including this
bill) Rs.
Signature of the Drawing Officer
Balance Rs.

Passed for Rs. ________________________

Signature of the Controlling Officer

Station :

Date : Received Contents

Examined & Entered

Treasury Accountant
Signature of the Drawing Officer
Date :

Pay Rs. __________________

For Use in the Audit Office

Admitted for Rs.

Objected to Rs.

Reasons for the objections :

Auditor Superintendent
(Gazetted Officer)
 APPLICATION FOR GRANT OF FESTIVAL ADVANCE

1. Name of applicant (in capital) Shri /Smt. / Kum.

2 Designation

3 Section to which attached

4 Particulars of Permanent / Quasi-permanent

post held, if any.
5 If temporary
a. Whether surety bond from another
Govt. Servant has been attached
b. Particulars of the surety

6 Present Pay excluding Allowances Rs.

7 Amount of advance required Rs.

8 Festival for which advance is applied for

9 If on leave, specify the nature and

particulars of leave.
10 Whether the applicant has drawn any Yes / No / N.A.
festival advance earlier during the current
calendar year.
11 Whether any festival advance drawn in the
previous calendar year has been fully
recovered or not. If not, give particulars.
12 Whether advance for Government Yes / No / N.A.
sponsored trip in hill station has been taken
during the current year.

I certify that the facts stated above are true to the best of my knowledge and belief.

Signature of the applicant with date

Section.
Sub Bill No.______________ No. 04

Leave Travel Concession Bill

For the Block Year ___________ to ____________
Note : This bill should be prepared in duplicate, one for payment and the other as office copy.
PART – A
[To be filled by the Government Servant]

1. Name of Officer / Official

2. Designation
3. Pay Rs.
4. Head Quarter
5. Nature and period of leave sanctioned E. L./C.L./E.O.L./R.H. from : _________ to _________
6. Particulars of members of family in respect of whom the LTC has been claimed.
Sr. No. Name Age Relationship with the
Govt. Servant.

7. Details of Journey(s) performed by Government Servant and the members of his/her family :
Departure Arrival Distance Mode of travel No. of Fare Paid
Date & From Date & To in Kms. & Class of Fares Rs.
Time Time Accommo-
dation
1. 2. 3. 4. 5. 6. 7. 8.

Remarks /Ticket Nos

8. Amount of Advance, if any drawn… Rs.

9. Particulars of Journey(s) for which higher class of accommodation than the one which the
Government Servant is entitled, was used (Sanction No. & date to be given).
Mode of Class to which Class by No. of Fare of the
Place Conveyance entitled which fares entitled
actually class.
From To travelled
1 2 3 4 5 6 7

10. Particulars of Journey(s) performed by Road between places connected by Rail.

Class to which Railway Fare
Name of Place entitled
From To
1 2 3 4

Certified that the :

1. Information as given above is true to the best of my knowledge and belief, and
2. The my wife/husband is not employed in Government Service/ that my wife/husband is
employed in Government Service and the concession has not been availed of by her/him
separately for herself/himself or for any of the family members for the concession block of
_______________ years.

Signature of the Government Servant

Date ______________________
 PART – B
[ To be filled in the Bill Section ]
The net entitlement on account of Leave Travel Concession works out to Rs. ________________ as
detailed below :

(a) Railway/Air/Bus/Steamer Fares

(b) Less : Amount of Advance drawn vide

Voucher No. Dated

(c) The Expenditure is debitable to Account.

Net Amount Rs.

Initials of the Bill Clerk

Signature of Drawing & Disbursing Officer

Signature of Controlling Officer

Certified that necessary entries have been made in the Service Book of Shri/Smt./Miss.

________________________.

Signature of the Officer authorised to

attest entries in the Service Book.
 APPENDIX - I
[Certificate to be given by the Controlling Officer]

Certified that :

1. Shri/Smt./Kum. _____________________________________________ has rendered

continuous service for one year or more on the date of commencing of outward
journey.

2. Necessary entries as required under para (52) of the scheme have been made in the
Service Book of Shri/Smt./Kum.
_________________________________________________.

3. Para 1(6) of MMA O.M. No. 43/1/55.Est.(A).Pt.II dated 11th October, 1956.

Signature of the Controlling Officer

[Certificate to be given by a Government Servant]

1) I have not submitted any other claim so far for Leave Travel Concession in respect
of myself or family members for the Block Year ____________________.

2) I have already drawn T.A. for the Leave Travel Concession in respect of a Journey
performed by me/with my spouse/ with children. This claim is in respect of the
journey performed by my spouse/ myself with my spouse/ and/or children / none of
whom travelled with the pary on the earlier occasion.

3) The journey has been performed by me and my spouse with children to the
declared “Home Town” / Other than Home Town viz. ____________________.

4) That my spouse is not employed in Government Service and the concession has not
been availed of by him/her separately for himself/herself or for any other family
member of the concerned block of two years.

5) Certified that my spouse for whom Leave Travel Concession 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 LTC facilities to its employees and their families.

Signature of the Govt. Servant.

 APPLICATION FOR ADVANCE FROM PROVIDENT FUND

1 Name of the subscriber

2 Account No.
3 Designation
4 Pay
5 Balance at credit of the subscriber on
the date of application as below
i) Closing balance as per statement
for the year ___________ .

ii) Credit from March ________ to

________, _______ on account of
monthly subscription.
iii) Refund.

iv) Withdrawals during the period from

__________ to ___________.
v) Net Balance at credit.

6 Amount of advance / outstanding if any,

and the purpose for which advance was
taken.
7 Amount of advance required
8 a. Purpose for which the advance is
required.
b. Rules under which the request is
covered.
9 Amount of the consolidated advance
(Items 6 & 7), number of monthly
installments in which consolidated advance
is proposed to be repaid.
10 Full particulars of the peculiar
circumstances of the subscriber,
justifying the application for the
advance.

Signature:_____________

Name :_______________
Designation :___________
PROFORMA FOR APPLICATION FOR WITHDRAWAL FROM PROVIDENT FUND
Ministry of :
Department of :
Office :

1 Name of the subscriber

2 Account No.
3 Designation
4 Pay
5 Date of joining and date of
superannuation.
6 Balance at credit of the subscriber on
the date of application as below
i) Closing balance as per statement
for the year ___________ .
ii) Credit from March ________ to
________, _______ on account of
monthly subscription.
iii) Refund made to the fund after
closing balance vide ( i ) above.
iv) Withdrawals during the period from
__________ to ___________.
v) Net Balance at credit at the time
of application.
7 Amount of withdrawal required.
8 a. Purpose for which the withdrawal is
required.
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 Accounts Officer
maintaining the Provident Fund Account.

Signature: ____________
Name: _______________
Designation:_______________
 FORM T. R. 58 - A
[See Rule 606 (1) and 609 – A]

Ministry/Department of _____________________________ Adjustable by __________________

Voucher No. ___________________
Dated _________________________
Bill for WITHDRAWING Final Payment/Advance/Other withdrawals/Payment under Deposit Linked
Insurance Scheme from General Provident Fund
For the month of__________________________
Sr. Name of Subscriber and Pay General No. and date of Final Payment/ Amount Payable
No. Provident sanction letter of Advance/ Other
Fund Account Authority Withdrawals/
No. Payment under
Deposit Linked
Insurance
Scheme

Total Rs.
Net amount required for payment (in words) Rupees
_______________________________________________________________________________________________ only.
Space for classification
Signature : ______________________________________

Designation of DDO ______________________________

Station : _____________________

Date : ______________________
Contents received.

Pay to

Signature of Drawing Officer __________________

Admitted Rs.

Objected Rs.

Accountant

Pay and Accounts Officer

Pay Rs.______________/- Examined and Entered
(Rupees ___________________________________

__________________________________________)

Treasury Officer/ Treasury Officer/

Pay & Accounts Officer Pay & Accounts Officer
 CERTIFICATE

1. Certified that I have satisfied myself that all sums included in bills in Form T. R. 58-A drawn 1
month/ 2 months/ 3 months previous to this date in favour of Mr./Mrs./Kum.
_______________________________________________________________ Account No.
_____________________ with the exception of those detailed below (of which the total has been
refunded by deduction from this bill) have been disbursed to the proper persons, and that their
acquittances have been taken in this bill/filled in my office with receipts stamp duly cancelled for
every payment in excess of Rs. 20. Certified also that the amount withdrawn previously on the
same account has been utilised by the subscriber for the purpose for which it was intended and
that the relevant premium receipt/receipts has/have been duly enfaced by me.

2. Certified that the balance at the credit of the subscriber on the date of the withdrawal covers the
sums drawn in the bill. Certified also that the amount asked for in this bill is required to meet the
premium due on _____________ in respect of Policy No. ________________________ with
the_____________________________________ and that the policy in question has been assigned
to the President of India and is in the custody of the Accounts Officer ________________________
_________________________________ (or the details of the policy proposed to be taken have been
communicated to the Pay and Accounts Officer
______________________________________________ and accepted by him in his letter No.
___________________________________ dated _______________________________). Certified
that the presentation of this claim/application for withdrawal of this amount has been/was made
within three months from the date of payment of the said premium.

3. Certified also that the number of policies financed from the General Provident Fund does not
exceed four/the number of policies financed from General Provident Fund exceed four as these
were accepted prior to 22nd June, 1975.

4. Certified that the amount claimed in this bill on account of dues under the Deposit Linked
Insurance Scheme is in accordance with the scales laid down in Ministry of Finance, Department
of Expenditure O.M. No. F. 9(10)(B)/7 dated 8th January, 1975 as amended from time to time.

Signature : _________________________________________________

Designation : _______________________________________________
 APPLICATION FOR ADVANCE FOR PURCHASE OF CYCLE

1. Name

2. Designation

3. Office in which working

4. Whether permanent/temporary

5. If temporary, name and designation of

the permanent Government Servant
who stands as surety (enclose Surety
Bond)
6. Basic Pay + Stagnation Increment

7. Anticipated price of the cycle

8. Amount of advance applied for

9. No. of instalments in which the advance

is desired to be repaid
10. a. Whether applied for first time

b. If not, details of cycle advance

drawn during the last three years -
(i) The date of drawal

(ii) Justification for fresh advance

[ In case of loss of cycle purchased previously, particulars of the report to the police also to be
mentioned ]

I declare that the particulars furnished above are correct and true to the best of
my knowledge.

Station :

Date : Signature of the Government Servant.

 APPLICATION FOR AN ADVANCE FOR PURCHASE OF MOTOR CYCLE/MOTOR
CAR/SCOOTER/MOPED/PERSONAL COMPUTER.

1. Name of the Applicant

2. Applicant’s Designation
3. District and Station
4. Basic pay + NPA + SI
5. Anticipated price of motor car/ motor cycle/
personal computer
6. Amount of advance required
7. Date of superannuation or retirement or date of
expiry of contract in case of a contract officer
8. No. of instalments in which the advance is desired to
be repaid
9. Whether advance for similar purpose was obtained
previously and if so -
(i) Date of drawal of the advance
(ii) The amount of advance and/or interest
thereon still outstanding, if any
10. Whether the intention is to purchase -
a. A new or an old motor car/motor
cycle/personal computer
b. If the intention is to purchase motor
car/motor cycle/ personal computer through a
person other than a regular or reputed dealer
or agent, whether previous sanction of the
competent authority has been obtained as
required under Rule 18(3) of the Central Civil
Services (Conduct) Rules, 1964
11. Whether the officer is on leave or is about to
proceed on leave -
a. The date of commencement of leave
b. The date of expiry of leave
12. Are any negotiations or preliminary enquiries being
made so that delivery may be taken of the motor
car/motor cycle/personal computer within one
month from the date of drawal of the advance
13. a. Certified that the information given above is complete and true
b. Certified that I have not taken delivery of the motor car/motor cycle/personal computer on
account of which I apply for the advance, that I shall complete negotiations for the purchase
of, pay finally and take possession of the same before the expiry of one month from the date
of drawal of the advance

Date : Signature of the Applicant.

 Med. 97
FORM OF APPLICATION FOR MEDICAL CLAIMS
Form of Application for claiming refund of medical expenses incurred in connection with
medical attendance and/or treatment of Central Government Servants and their families - For
medical attendance/treatment taken both from an Authorized Medical Attendant and a Hospital.

1. Name & Designation of Government

Servant (in Block letters).
(i) Whether married or unmarried.
(ii) If married, the place where wife/ husband
is employed.
2. Office in which employed.
3. Pay of the Government Servant as defined
in the Fundamental Rules and any other
emoluments which should be shown
separately.
4. Place of duty
5. Actual Residential address

6. Name of the patient and his/her

relationship to the Government Servant.
N.B.- in case of children state age also.
7. Place at which the patient felt ill.
8. Details of the amount claimed -
I. Medical Attendance -
(i) Fees for consultation indicating -
(a) the name and designation of the Medical
officer consulted and the Hospital or
dispensary to which attached.
(b) the number and date of consultation and
the fee paid for each consultation
(c) the number and dates of injection and fee
paid for each injection
(d) whether consultations and/or injections
were had at the hospital, at the consulting
room of the Medical Officer or at the
residence of the patient.
(ii) Charges for Pathological, Bacteriological,
Radiological, or other similar tests
undertaken during diagnosis indicating –
(a) the name of the hospital or laboratory
where undertaken; and
 (b) Whether the tests were undertaken on the
advice of the Authorised Medical
Attendant. If so, a certificate to that effect
should be attached
(iii) Cost of medicines purchased from the
market (Cash memos and the Essentiality
Certificates should be attached)
II. Hospital Treatment
Name of the Hospital

Charges for hospital treatment, indicating

separately, the charges for -
(i) Accommodation
(State whether it was according to the
status or pay of the Government Servant
and in cases where the accommodation is
higher than the status of the Government
Servant, a certificate should be attached to the
effect that the accommodation to which he
was entitled was not available)
(ii) Diet
(iii) Surgical operation or medical treatment
or confinement.
(iv) Pathological, Bacteriological, Radio-
logical or other similar tests, indicating -
(a) the name of the hospital or laboratory at
which undertaken; and
(b) whether undertaken on the advice of the
Medical Officer in charge of the case at
the hospital. If so, a certificate to that
effect should be attached.
(v) Medicines
(vi) Special medicines (Cash memos and the
Essentiality Certificates should be attached)

(vii) Ordinary nursing

(viii) Special nursing, i.e. nurses, specially
engaged for the patient. State whether
they are employed on the advice of the
Medical Officer in charge of the case at
the hospital or at the request of the
Government Servant or patient. In the
former case a certificate from the Medical
Officer in charge of the case and
countersigned by the Medical
Superintendent of the hospital should be
attached.
(ix) Ambulance charges (State the journey – to
and fro – undertaken)
(x) Any other charges, e.g. Charges for
electric light, fan, heater, air-conditioning,
etc. State also whether the facilities
referred to are a part of the facilities
normally provided to all patients and no
choice was left to the patient.
Note 1 If the treatment was received by the Government Servant at his residence under Rule 7 of the
CS (MA) Rules, 1944, give particulars of such treatment and attach a certificate from the
Authorised Medical Attendant as required by these rules.
Note 2 If the treatment was received at a hospital other than a Government Hospital, necessary
details and the certificate of the Authorised Medical Attendant that the requisite treatment
was not available in any nearest Government Hospital should be furnished.
III. Consultation with Specialist
Fees paid to a Specialist or a Medical
Officer other than the Authorised Medical
Attendant, indicating -
(a) the name and designation of the Specialist
or Medical Officer consulted and the
hospital to which attached.
(b) number and dates of consultations and the
fees charged for each consultation.
(c) whether consultation was had at the
Hospital, at the consulting room of the
Specialist or Medical Officer or at the
residence of the patient; and
(d) whether the Specialist or Medical Officer
was consulted on the advice of the
Authorised Medical Attendant and the
prior approval of the Chief Administrative
Medical Officer of the State was obtained.
If so, a certificate to that effect should be
attached.
9. Total Amount claimed Rs.
10. Less advance taken on Rs.
11. Net Amount claimed Rs.
12. List of Enclosures :
 DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me.

Signature of the Government Servant

and the office to which attached
 Med. 97-A
FORM OF APPLICATION FOR MEDICAL CLAIMS
Form of Application for claiming refund of medical expenses incurred in connection with
medical attendance/treatment of Central Government Servants or their families for treatment in
a Hospital.

1. Name & Designation of Government

Servant (in Block letters).
(i) Whether married or unmarried.
(ii) If married, the place where wife/ husband is
employed.
2. Office in which employed.
3. Pay of the Government Servant as defined in
the Fundamental Rules and any other
emoluments which should be shown
separately.
4. Place of duty
5. Actual Residential address

6. Name of the patient and his/her

relationship to the Government Servant.
N.B.- in case of children state age also.
7. Place at which the patient felt ill.
8. Details of the amount claimed -
I. Hospital Treatment -
Name of the Hospital

Charges for hospital treatment, indicating

separately, the charges for -
(i) Accommodation (State whether it was
according to the status or pay of the
Government Servant and in cases where the
accommodation is higher than the status of the
Government Servant, a certificate should be
attached to the effect that the accommodation to
which he was entitled was not available)
(ii) Diet
(iii) Surgical operation or medical treatment
or confinement.

(iv) Pathological, Bacteriological, Radio-logical

or other similar tests, indicating -
(a) the name of the hospital or laboratory at
which undertaken; and
 (b) whether undertaken on the advice of the
Medical Officer in charge of the case at the
hospital. If so, a certificate to that effect
should be attached.
(v) Medicines

(vi) Special medicines (Cash memos and the

Essentiality Certificates should be attached)

(vii) Ordinary nursing

(viii) Special nursing, i.e. nurses, specially
engaged for the patient. State whether they
are employed on the advice of the Medical
Officer in charge of the case at the hospital
or at the request of the Government Servant
or patient. In the former case a certificate
from the Medical Officer in charge of the
case and countersigned by the Medical
Superintendent of the hospital should be
attached.
(ix) Ambulance charges (State the journey - to
and fro – undertaken)

(x) Any other charges, e.g. Charges for electric

light, fan, heater, air-conditioning, etc. State
also whether the facilities referred to are a
part of the facilities normally provided to all
patients and no choice was left to the
patient.
Note 1 If the treatment was received by the Government Servant at his residence under Rule 7 of the
CS (MA) Rules, 1944, give particulars of such treatment and attach a certificate from the
Authorised Medical Attendant as required by these rules.
Note 2 If the treatment was received at a hospital other than a Government Hospital, necessary details
and the certificate of the Authorised Medical Attendant that the requisite treatment was not
available in any nearest Government Hospital should be furnished.
II. Consultation with Specialist
Fees paid to a Specialist or a Medical
Officer other than the Authorised Medical
Attendant, indicating -
(a) the name and designation of the Specialist
or Medical Officer consulted and the
hospital to which attached.
(b) number and dates of consultations and the
fees charged for each consultation.
(c) whether consultation was had at the
Hospital, at the consulting room of the
Specialist or Medical Officer or at the
residence of the patient; and
(d) whether the Specialist or Medical Officer
was consulted on the advice of the
Authorised Medical Attendant and the prior
approval of the Chief Administrative
Medical Officer of the State was obtained. If
so, a certificate to that effect should be
attached.
9. Total Amount claimed Rs.
10. Less advance taken on Rs.
11. Net Amount claimed Rs.
12. List of Enclosures :

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me.

Signature of the Government Servant

and the office to which attached
 Med. 97-B
FORM OF APPLICATION FOR MEDICAL CLAIMS
Form of Application for claiming refund of medical expenses incurred in connection with
medical attendance and/or treatment of Central Government Servants and their families - For
Medical Attendance by Authorized Medical Attendant.

1. Name & Designation of Government

Servant (in Block letters).
(i) Whether married or unmarried.
(ii) If married, the place where wife/ husband is
employed.
2. Office in which employed.
3. Pay of the Government Servant as defined
in the Fundamental Rules and any other
emoluments which should be shown
separately.
4. Place of duty
5. Actual Residential address

6. Name of the patient and his/her

relationship to the Government Servant.
N.B.- in case of children state age also.
7. Place at which the patient felt ill.
8. Details of the amount claimed -
I. Medical Attendance -
(i) Fees for consultation indicating -
(a) the name and designation of the Medical
officer consulted and the Hospital or
dispensary to which attached.
(b) the number and date of consultation and
the fee paid for each consultation
(c) the number and dates of injection and fee
paid for each injection
(d) whether consultations and/or injections
were had at the hospital, at the consulting
room of the Medical Officer or at the
residence of the patient.
(ii) Charges for Pathological, Bacteriological,
Radiological, or other similar tests
undertaken during diagnosis indicating –
(a) the name of the hospital or laboratory
where undertaken; and
 (b) whether the tests were undertaken on the
advice of the Authorised Medical
Attendant. If so, a certificate to that effect
should be attached
(iii) Cost of medicines purchased from the
market (Cash memos and the Essentiality
Certificates should be attached)
II. Consultation with Specialist -
Fees paid to a Specialist or a Medical
Officer other than the Authorised Medical
Attendant, indicating -
(a) the name and designation of the Specialist
or Medical Officer consulted and the
hospital to which attached.
(b) number and dates of consultations and the
fees charged for each consultation.
(c) whether consultation was had at the
Hospital, at the consulting room of the
Specialist or Medical Officer or at the
residence of the patient; and
(d) whether the Specialist or Medical Officer
was consulted on the advice of the
Authorised Medical Attendant and the
prior approval of the Chief Administrative
Medical Officer of the State was obtained.
If so, a certificate to that effect should be
attached.
9. Total Amount claimed Rs.
10. Less advance taken on Rs.
11. Net Amount claimed Rs.
12. List of Enclosures :

DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the application are true to the best of my knowledge and
belief and that the person for whom medical expenses were incurred is wholly dependent upon me.

Signature of the Government Servant

and the office to which attached
 ESSENTIALITY CERTIFICATES
C E R T I F I C A T E – ‘A’

(To be completed in the case of patients who are not

admitted to hospital for treatment)

Certificate granted to Mr./Mrs./Miss __________________________________,

husband/wife/son/daughter of Mr./Mrs./Miss ___________________________________ employed in
the _________________________________________.

I, Dr. _________________________________________________ hereby certify

(a) that I charged and received Rs._______________ for ______________ consultations on

_________________________ (dates to be given) at my consulting room/ at the residence of the
patient;

(b) that I charged and received Rs.____________ for administering intra-venous/Intra-muscular/

subcutaneous injections on_______________________(dates to be given) at _________________ my
consulting room/at the residence of the patient;

(c) that the injections administered were not/were for immunizing or prophylactic purposes;

(d) that the patient has been under treatment at __________________________ hospital/my consulting
room and that the undermentioned medicines prescribed by me in this connection were essential for the
recovery/prevention of serious deterioration in the condition of the patient. The medicines are not
stocked in the_________________(name of hospital) for supply to private patients and do not include
proprietary preparations for which cheaper substances of equal therapeutic value are available nor
preparations which are primarily foods, toilets or disinfectants.

Name of Medicines Price

(e) that the patient is/was suffering from ______________________________ and is/was under
treatment from _________________ to _____________________.

(f) that the patient is/was not given pre-natal or post-natal treatment.

(g) that the X-ray, laboratory test, etc., for which an expenditure of Rs. ____________ /- was incurred
was necessary and were undertaken on my advice at ________________________________ (name of
the Hospital or laboratory).
(h) that I referred the patient to Dr. _____________________ for Specialist Consultation and that the
necessary approval of the _________________(name of the Chief Administrative Officer of the State)
as required under the rules was obtained.;

(i) that the patient did not require/required hospitalisation

Date:
Signature of A.M.A./ Designation of the
Medical Officer and hospital/
dispensary to which attached

N.B. - Certificates not applicable should be struck off. Certificate (e) is compulsory and must be filled
in by the Medical Officer in all cases.

Note-1 : In case where double the rates of consultation fees are charged by the AMA for night visit
(between 10 p.m. and 6 a.m.) The AMA should furnish a certificate showing why the night
consultation was necessary.
[G.I., M.H.,O.M.No. F - 28-57/60-H.I dated the 4th April, 1962]

Note-2 : The above certificate may be deemed to be regular receipt for the payment received by the
Medical Officers who will be required to affix a revenue stamp on Essentiality Certificate itself when
the payment exceeds Rs.20. Separate receipt(stamped where necessary) would however be
necessary from the Specialist for consultation with them, who do not sign the Essentiality
Certificate.
[G.I., M.H., O.M.No. F - 28-8/60-H.I. dated the 30th January, 1961]

Note-3 Where the receipt issued by the Government Hospitals are on authorised forms(printed and
numbered) and amount of these receipt is incorporated in the body of the Essentiality Certificate,
countersignature of such receipt need not be insisted upon.
[G.I., M.H., O.M.No.F - 61(1)-E.V/60 dated the 29th February, 1960]
 C E R T I F I C A T E – ‘B’

(To be completed in the case of patients who are

admitted to hospital for treatment)

Certificate granted to Mr./Mrs./Miss __________________________________,

husband/wife/son/daughter of Mr./Mrs./Miss ___________________________________ employed in
the _________________________________________.

PART – A

I, Dr. _________________________________________________ hereby certify

(a) that the patient was admitted to ________________________________________ hospital on the

advice of _______________________________________ (name of the Medical Officer)/on my
advice;

(b) that the patient has been under treatment at __________________________ hospital/my consulting
room and that the undermentioned medicines prescribed by me in this connection were essential for the
recovery/prevention of serious deterioration in the condition of the patient. The medicines are not
stocked in the____________________________(name of hospital) for supply to private patients and
do not include proprietary preparations for which cheaper substances of equal therapeutic value are
available nor preparations which are primarily foods, toilets or disinfectants.

Name of Medicines Price

(c) that the injections administered were /were not for immunizing or prophylactic purposes;

(d) that the patient is/was suffering from ______________________________ and is/was under
treatment from _________________ to _____________________;

(e) that the X-ray, laboratory test, etc., for which an expenditure of Rs. ____________ /- was incurred
was necessary and were undertaken on my advice at ________________________________ (name
of the hospital or laboratory);
(f) that I called on Dr. _____________________ for Specialist Consultation and that the necessary
approval of the _________________(name of the Chief Administrative Officer of the State) as
required under the rules was obtained;

Date:
Signature and Designation of the Medical
Officer in charge of the case at the hospital

PART – B

I certify that the patient has been under treatment at the __________________________
hospital and that the service of the special nurses for which an expenditure of Rs. _____________ was
incurred, vide bills and receipts attached, were essential for the recovery/prevention of serious
deterioration in the condition of the patient.

Signature of the Medical Officer

in charge of the case at the hospital
 COUNTERSIGNED

Medical Superintendent

______________________ Hospital

I, certify that the patient has been under treatment at _______________________

_________________________________ hospital and that the facilities provided were the minimum
which were essential for the patient’s treatment.

Place : Medical Superintendent

_____________Hospital

Note:- Certificate not applicable should be struck off. Certificate (d) is compulsory and must be filed in
by the Medical Officer in all cases
 APPLICATION FOR ADVANCE OF PAY ON
TRANSFER

1. Name of the Officer/ Official.

2. Designation & Office.

3. Whether permanent / temporary.

4. If temporary, name and designation of

the permanent Government Servant
furnishing the surety bond.
5. Station in which working.

6. Station to which transferred.

7. Pay* drawn at the time of transfer.

8. No. & Date of transfer order/s.

9. Whether transfer is in public interest.

10. Amount of advance required.

I declare that the particulars furnished above are correct.

Station :
Signature of the Government Servant.
Date :
 APPLICATION FOR ADVANCE OF T.A. ON TOUR

1. Name of the Officer/ Official.

2. Designation.

3. Whether permanent / temporary.

4. Office/Section in which working.

5. Basic Pay + NPA + SI.

6. Places to be visited and period of halt

at each station.

7. Purpose of tour.

8. Has the tour programme been

approved by competent authority ?
9. Duration of journey (in days).

10. Rail/Road fare by the entitled class by

which the Government Servant
proposes to travel for both outward
and inward journeys.
11. Daily allowance entitled -
(i) For journey period Rs.
(ii) For the halts Rs.
Total Rs.
12. Total T.A. + D.A. ( 10 + 11)
13. Amount of Advance required
14. Whether any earlier advance is
outstanding. If so, the date on which
T.A. bill was submitted.

I declare that the particulars furnished above are correct.

Station :
Signature of the Government Servant.
Date :
 APPLICATION FOR ADVANCE OF T.A. ON
TRANSFER
1. Name of the Officer/ Official.

2. Designation.

3. Whether temporary / permanent.

4. Office/Station in which working.

5. Basic Pay + NPA + SI.

6. Station to which transferred.

7. No. & Date of the transfer order.

8. Details of family members alongwith

their age and relationship.
Family Particulars Age Relationship

9. Whether the advance is required for.

(a) Self alone, or
(b) Self and family, or
(c) Family alone
10. Amount of advance required

I declare that the particulars furnished above are correct.

Station :
Signature of the Government Servant.
Date :
 APPLICATION FOR ADVANCE OF T.A. ON
RETIREMENT
1. Name of the Officer/ Official.

2. Designation.

3. Office in which working.

4. Station in which working.

5. Whether permanent/temporary.

6. Basic Pay + NPA + SI.

7. Details of family members alongwith

their age and relationship.
Family Particulars Age Relationship

8. Station at which desires to settle after

retirement.
9. Date from which the official is on LPR
(Leave Preparatory to Retirement).
10. Date of superannuation.
11. Date on which journey is proposed to
be performed.
12. Amount of advance required.

I declare that the particulars furnished above are correct and true to the best of
my knowledge.

Station :
Signature of the Government Servant.
Date :

[ NOTE – Advance admissible only if the journey is performed during LPR ]

 APPLICATION FOR ADVANCE OF T. A. TO THE FAMILY
OF A DECEASED EMPLOYEE
1. Name of the Applicant.

2. Relationship with the deceased

Government Servant.
3. Name of the deceased Government
Servant.
4. Post held by the deceased Government
Servant.
5. Headquarters of the deceased
Government Servant.
6. Basic Pay + NPA + SI drawn by the
deceased Government Servant.
7. Details of family members alongwith
their age and relationship.
Family Particulars Age Relationship

8. Place at which the family members

desire to settle.
9. Whether surety from a permanent
Government Servant is enclosed.
10. Amount of advance required.

I declare that the particulars furnished above are correct and abide by the
conditions for the recovery of advance. I am also enclosing the surety bond from a permanent
Central Government Servant.

Station :
Signature of the Applicant.
Date :
 FORM GFR 37

APPLICATION FOR FLOOD/DROUGHT ADVANCE

Name of the Ministry/Deptt./Office

1. Name of the Applicant.

2. Designation

3. Basic Pay + SI

4. Whether Permanent/Temporary

5. Section/Office to which attached

6. Permanent Address

7. Present Residential Address

8. Details of the property movable /

immovable affected or damaged by the
natural calamity -
(i) Name of the place which has
been affected by the natural
calamity and the details of the
property immovable as well as
movable (to be shown separately
in two lists) damaged.
 8. (ii) Whether any advance was
drawn on earlier occasion and if
so, the date of drawal and
amount.
(iii) Whether the earlier advance was
drawn for damage to the same
movable or immovable property
and if so, the nature of further
damage to the movable or
immovable property to be
indicated precisely
(iv) If reply to item (iii) is in the
affirmative the details of damage
that has now occurred requiring
fresh assistance (list to be
attached indicating details)
(v) Whether the recovery of
advance has since been
completed.
9. Amount of advance required.

______________________
Dated (Signature of Applicant)

Declaration
I, ___________________________, do hereby declare that the statements furnished in
item 8 above are correct.

______________________
Dated (Signature of Applicant)

Warning - If at any stage the information furnished above is found untrue, the sanctioning
authority may take disciplinary action against the official under the rules.
 APPLICATION FOR L.T.C. ADVANCE
1. Name of the official (in Block Letters).
2. (a) Designation and Staff No.
(b) Permanent or Temporary.
[ If not permanent, Surety Bond
from a permanent official to be
enclosed with the Application ]
3. Unit/Office to which attached.
4. Basic Pay + NPA + SI in the present
Grade.
5. Date of appointment in the Department.
6. Place of home town as declared in the
Service Book.
7. Particulars of LTC availed for previous
Block Years.
8. Block Year for which now proposed to
avail.
9. Whether avails CL or EL (Nature of
Leave to be mentioned).
10. Whether LTC advance already taken has
been settled in full or pending settlement,
date of the settlement of the previous
case.
11. Place of visit (farthest point).
12. Proposed Date of onward journey.
13. Probable Date of return journey.
14. Particulars of family members availing
the facility.
S. No. Name Relationship Age Whether dependant

15. Class of accommodation proposed to be

availed in the Railway journey.
16. Amount of advance required.

Date (Signature & Design. of Official)

 DECLARATIONS

I, _____________________________, hereby certify that the above particulars furnished

by me are true and correct.

I also undertake to refund the LTC advance in full immediately in case of failure to
perform the proposed journey for which advance was taken.

I also declare that I will not visit other than the place mentioned in the application
without obtaining prior approval of the competent authority.

I also agree to refund one half of the advance if the return journey could not be
performed within 60 days from the date of the advance.

I also agree to credit forthwith to the office any excess amount of advance left with me for
any reason whatsoever.

I also agree to produce evidence of purchase of tickets, etc., for myself/members of my

family, as the case may be, for the forward journey within 10 days or before the commencement
of the journey, whichever is earlier, from the date of drawing the advance. I am aware that
failure to comply with the above requirement will entail recovery of the advance in one lumpsum
from the next drawal of my salary, together with the penal interest @ 21/2 % over and above the
normal interest.

I am aware that if I do not submit LTC bills within one month from the date of return
journey the outstanding LTC advance is recoverable in one lumpsum from my next salary
together with the penal interest @ 21/2 % over and above the normal interest.

I am also aware that my claim will be forfeited if I fail to submit the bills within 1 month
from the date of completion of journey.

I also understand that if the LTC is availed for self, the cost is reimbursable only when
the journey is performed after availing any kind of leave and not during week-end
holidays/other holidays/RH alone.

Signature: ________________

Designation: _______________

REMARKS OF THE UNIT OFFICER

Forwarded. Official applied CL/EL as at Col. 9 and the same has been sanctioned.

Unit Officer
 APPLICATION FOR LEAVE SALARY ADVANCE
1. Name.

2. Designation

3. Office / Section to which attached

4. Basic Pay + NPA + SI

5. Nature and period of leave sanctioned

and Sanction Order No. and date

6. Total Pay and Allowances entitled (i.e.

Pay, DA, HRA, CCA, etc., per mensem)
7. Total recoveries per mensem

8. Amount of advance applied for

I declare that the particulars furnished above are correct.

Station :
Signature of the Government Servant.
Date :
 APPLICATION FOR ADVANCE FOR MEDICAL
TREATMENT

1. Name.

2. Designation and Office in which working.

3. Basic Pay + NPA + SI

4. Whether permanent or temporary.

5. Name of the patient and relationship with

the Government Servant.
6. Nature of illness.

7. Whether treatment is received as In-

patient or Out-patient.
8. Name of the Hospital in which patient is
treated and whether it is a recognised
one.
9. Whether necessary certificate from the
Medical Officer or Specialist of the
recognised hospital is enclosed.
10. Anticipated cost of treatment as certified
by the Medical Officer/Specialist.
11. Amount of advance required.

I declare that the particulars furnished above are correct.

Station :
Signature of the Government Servant.
Date :
 FORM OF APPLICATION FOR CLAIMING REFUND OF MEDICAL TREATMENT
INCURRED IN CONNECTION WITH MEDICAL ATTENDANCE AND/OR TREATMENT
OF CENTRAL GOVT. SERVANTS AND THEIR FAMILIES.

1. Name and designation of the

Government Servant (in block letters)
2. Office in which employed

3. Pay & Allowance to be shown

separately –
Pay, DA, CCA, HRA = Total
4. Place of Duty

5. Actual Residential Address

6. Name of patient and his/her

relationship to the Govt. Servant
7. Place at which the patient fell ill

8. Details of Amount claimed

(i) Medical Attendance :

(a) Name, Address & Designation of the

Medical Officer consulted and the
hospital or dispensary in which
attached.
(b) No. & date of consultation and fees
paid for each consultation.
(c) No. & date of injections and fees
paid for each injection.
(d) Whether consultation or injections
were had at the hospital/consulting
room or at the residence of the
patient.
(ii) Indoor Hospital Treatment

(iii) Medicines purchased from the

market. (List of medicines, cash memo
& essentiality certificate should be
attached)
9. Total Amount Claimed

10 List of Enclosures 1. Doctor’s prescription(s)

2. Cash Memo(s)
3. Essentiality Certificate
4. Other (Please Specify) _______________________
 DECLARATION TO BE SIGNED BY THE GOVERNMENT SERVANT

I hereby declare that the statements in the application are true to the best of my knowledge and
belief and that the person for whom Medical Expenses were incurred is wholly dependent upon me.

Place :
Signature of the Government Servant.

Certificate granted to ____________________________________ son/daughter/wife/husband

of Mr./Mrs. _________________________________ employed in the __________________________

department at _______________________.

CERTIFICATE
(To be completed in the case of patients who are not admitted in the hospital for treatment)

I, Dr. ______________________________________________ hereby certify that

(a) I charged and received Rs. ____________ for consultation/s on ___________________.

(b) I charged and received Rs. ____________ for administering __________________

intramuscular injections or subcutaneous on ______________ at my consulting room / the

residence of the patient. (dates to be given)

(c) That the injections administered were/not for immunizing or prophylactic purposes,

(d) That the patient has been under treatment at ____________________________ hospital/my
consulting room and the undermentioned medicines prescribed by me in this connection were
essential for the recovery/prevention of serious deterioration in the condition of the patient and
the medicines are not stocked in the _________________ (name of hospital) for supply to
private patients and do not include proprietary preparations for which cheaper substances of
equal therapeutic value are available; no preparations which are primarily foods, toilets or
disinfectants;
 Name of the Medicines Price

(e) that the patient is suffering from _______________________________ and is under my

treatment from __________________ to ___________________;
(f) that the patient is/was not given pre-natal or post-natal treatment;
(g) that the X-ray, Laboratory tests, etc., for which an expenditure of Rs. ___________________
has been incurred was necessary and were undertaken on my advice at ___________________.
(h) That I referred the patient to Dr. __________________________________ for specialists
consultation and that the necessary approval of the ______________________________ (Name
of the Chief/Administrative/Medical Officer of State) under the rules was obtained;
(i) That the patient did not require/required hospitalisation.

Place :
Signature of the Authorised Medical Attendant
Date :
 FORM OF APPLICATION FOR FINAL PAYMENT/TRANSFER TO
CORPORATE BODIES/OTHER GOVERNMENTS OF BALANCES IN THE
GENERAL PROVIDENT FUND ACCOUNT.

To

The Accounts Officer,

_____________________________

_____________________________

_____________________________

Submitted 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 Central 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 the 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 year _________________
(enclosed)/as appearing in my ledger account being maintained by you
______________________________ Treasury/Sub-Treasury/Head of Office, may please be arranged
to be paid to me as first instalment of final payment.
5. After payment of the first instalment of my Provident Fund balance. I will apply for the
payment of subsequent instalments 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 Accounts Officer, Zonal Accounts Office, CBDT, Ahmedabad 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.

[Signature of the Head of Office]

 PART-II

[To be submitted by the Subscriber immediately after his 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 Accounts Officer, Zonal Accounts Office, CDBT, Ahmedabad for necessary
action/in continuation of Endorsement No. _____________________________ dated
_______________.

2. He/She has finally retired/will proceed on leave preparatory to retirement for

____________________ months/has been discharged/dismissed/has been permanently transferred to
___________________/has resigned finally from Government service/has resigned service under
____________________ Government to take up appointment with ________________ and his/her
resignation has been accepted with effect from _____________________ forenoon/afternoon. He 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
______________________________________________________________ only) 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 temporary 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/ Date Voucher

Withdrawal Number
1.

2.

3.

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

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

____________________________________
(Signature of Head of Office/Department.)
 REIMBURSEMENT OF TUITION FEE

Certified that the child/children mentioned below in respect of whom reimbursement of

tuition fee/s is claimed is/are wholly dependent upon me :

Name of the Child Date of School in which studying Class in Monthly Tuition Amount of
Birth which tuition fee fee reimburse-
Studying actually actually ment
payable payable
for the
year
1 2 3 4 5 6 7

2. Certified that the tuition fee/s indicated against the child/each of the children had actually been
paid by me. (Cash receipts, Bank credit vouchers, etc., to be attached with the initial claim only).

3. Certified that : -

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

ii) My wife/husband is a Central / State Government servant, but she/he will not claim the
reimbursement of tuition fee in respect of our child/children.
iii) My wife/husband is employed with __________________________________. She/he is
not entitled to reimbursement of tuition fees in respect of our child/children.
4. Certified that during the period covered by this claim, the child/children attended the school(s)
regularly and did not absent himself/herself/themselves from the school(s) without proper leave for
a period of exceeding one month.
5. Certified that the child/children mentioned has/have not been studying in the same class for more
than two years.
6. Certified that I or my wife/husband have/has not claimed and will not claim the Children’s
Educational Allowance in respect of the child/children mentioned above.
7. Certified that my child/children in respect of whom reimbursement of tuition fee is claimed is/are
studying in the school(s) which is/are recognised school(s).
8. In the event of any change in the particulars above which effect my eligibility for reimbursement of
tuition fees, I undertake to intimate the same promptly and also to refund excess payments, if any
made.

Signature of the Govt. Servant.

Place : Name in block letters ___________________________
Date : Designation & Office __________________________
MSO (T)16
LAST PAY CERTIFICATE
(See Appendix B)

Last Pay Certificate of Shri/Smt./Kum.______________________________________ of the

__________________________________ proceeding on transfer/promotion/retirement to the office of
______________________________________.

2. He/She has been paid up to _____________, 20 at the following rates :

Earnings Deductions
Particulars Rate (%) Amount Particulars Amount
Substantive/Officiating/
Income-tax Deduction
Basic Pay
General Provident Fund
Dearness Pay
Contribution
Dearness Allowance C.G.H.S.

House Rent Allowance C.G.I.S./ N.G.I.S.

House Bldg. Advance /
City Comp. Allowance
Interest.
Conveyance / Computer
Transport Allowance
Advance / Interest.
Personal Pay Festival Advance
General Provident Fund
Special Pay
Advance
Washing Allowance License Fee

Interim Relief Water Charges

Medical Allowance Other Deduction/s

Any Other / Salary
Leave Travel Allowance
Advance
Other (Please specify) Professional Tax

Total Earnings Total Deductions

Net Salary Paid

3. His/Her General Provident Fund Account No. _______________ is maintained by Accounts

Officer/Accountant General ____________________________, _________________________.
4. He/She made over the charge of the office of _________________________________ on the
Forenoon/Afternoon of _________________________.
5. Recoveries are to be made from the pay of the Government Servant as detailed below :
Nature of Recovery Amount to be In No. of Out of total
recovered instalments instalments of

6. He/She has been paid Leave Salary as detailed below.

Period Rate @ Rs. Per Month Amount
From To

7. Deductions has been made from the Leave Salary as noted below :

Period of Leave Salary On Account of Amount

From To

8. He/She is also entitled to a joining time for ______________________days.

9. He/She has availed Casual Leave____________ and/or Restricted Holiday ________________.
10. He/She finances the insurance policies detailed below from Provident Fund :
Name of the Insurance No. of Policy Amount of Premium Due date for the date
Company of Premium

11. The details of the Income tax recovered from him/her upto the date from the beginning of the
current Financial Year are noted in the reverse.

Place :
Date :
______________________________________
Signature of Drawing & Disbursing Officer
 Details of Deductions made during the current Financial Year
Month/ Gross GPF GPF Income HBA Conv. CGIS CGHS Wtr. Lcn. Fest. Comp. Prof. Other
Year Salary Cont. Adv. Tax Adv. Chrg. Fees Adv. Adv. Tax Ded.
Mar.
Apr.
May.
Jun.
Jul.
Aug.
Sep.
Oct.
Nov.
Dec.
Jan.
Feb.
Total
 FORM NO. 37-B
Bill No.________________

Dated : ________________

Head of Account : " 2071 - Pension & Gratuity - Retirement

Benefits, Other Benefits etc."

Received the sum of Rs.______________/- (Rupees

_____________________________________________________________________only) due to
Shri. / Smt._________________________________________________________________ being the
amount of D.C.R.G. / Comm. Value of Pension / Family Pension /Provisional Pension sanctioned
vide Order / Letter No. _____________________________________ dated ___________ for Rs.
____________________________.
Rs.
Bill Amount
Rs.
Total Deduction
Rs.
Net Amount Payable

Rupees

______________________________________
Signature of Drawing & Disbursing Officer
Countersigned for Rs. _______________.

______________________________________
Signature of Drawing & Disbursing Officer

For use in the Zonal Accounts Office

Audited Rs. _____________

Objected Rs. ____________

Reasons for Objection.

Auditor Sup. Accounts Officer

Date: Date: Date:
 FORM T. R. - 42
(See Rule 406)

Bill No. :_________________

Head of Account
Date : ___________________

Received the sum of Rs.________________/- (Rupees

_______________________________________________________________ only) being the
advance for purchase of Motor Car/Motor Cycle/Scooter/Moped/Computer/Bicycle for F.Y.
________________ sanctioned by the __________________________________________ vide his
order No. ___________________________________________________ dated _____________
(copy/copies enclosed) in respect of Shri/Smt./Kum. _________________________________.

Grant for the Year ___________________ Rs.

Expenditure upto this Bill Rs.
Balance Rs.

Signature of Drawing & Disbursing Officer

Countersigned for Rs._______________

FOR USE IN PRE-CHECK UNIT

Pay Rs.

Examined

Accountant Accounts Officer.

FOR USE IN ZONAL ACCOUNTS OFFICE

Admitted Rs.____________

Objected Rs.____________

Reasons for objection :

Auditor Superintendent Gazetted Officer.

 FORM T. R. - 42
(See Rule 406)

Bill No. :_________________

Head of Account
Date : ___________________

Received the sum of Rs.________________/- (Rupees

_______________________________________________________________ only) being the House
Building Advance for purchase of a Flat/House/Plot of Land or for constructing/reconstructing a
flat/house for F.Y. ________________ sanctioned by the
__________________________________________ vide his order No.
___________________________________________________ dated _____________ (copy/copies
enclosed) in respect of Shri/Smt./Kum. _________________________________.

Grant for the Year ___________________ Rs.

Expenditure upto this Bill Rs.
Balance Rs.

Signature of Drawing & Disbursing Officer

Countersigned for Rs._______________

FOR USE IN PRE-CHECK UNIT

Pay Rs.

Examined

Accountant Accounts Officer.

FOR USE IN ZONAL ACCOUNTS OFFICE

Admitted Rs.____________

Objected Rs.____________

Reasons for objection :

Auditor Superintendent Gazetted Officer.

 A N N E X U R E “C”

Received the sum of Rs.______________ (Rupees

_____________________________________ only ) being the total of entitlement of Rs.
______________ from the insurance Fund and/or of Rs. ____________ from the Savings Fund,
accrued to _____________________________________ Designation _____________ Group
A/B/C/D under the Central Government Employees' Group Insurance Scheme.

Date : Signature(s) of Recipient(s)

(Name in block letters)

FOR USE IN DEPARTMENTAL OFFICE

(A) Relevant Bio data of the Members Type or Group

(Viz. “A”, “B”, “C”, “D”)
I Type or Group of the Member (i.e. lowest group on initially
Type : -
joining the scheme on …
2. Year of acquiring Membership of the higher group : Group “C” on
Group “B” on
Group “A” on
(B) Countersigned for payment of Rs. _________________ /-
(Rupees _______________________________________________________________ only)
to claimant(s). Crossed Cheque/Demand Draft to be issued in favour of claimant(s).

Signature of Drawing & Disbursing Officer

FOR USE IN PAY AND ACCOUNTS OFFICE.

Passed for payment of Rs. ______________/- (Rupees

__________________________________________________) Payment through Cheque(s) No.(s)
__________________________ dated ______________.

PAY & ACCOUNTS OFFICER.

 FORM T. R. - 42
(See Rule 406)

Bill No. :_________________

Head of Account
Date : ___________________

Received the sum of Rs.________________/- (Rupees

_______________________________________________________________ only) being the
amount payable under the "DEPOSIT LINKED INSURANCE SCHEME" sanctioned by the
__________________________________________ vide his order No.
___________________________________________________ dated _____________ (copy/copies
enclosed) in respect of Shri/Smt./Kum. _________________________________.

Grant for the Year ___________________ Rs.

Expenditure upto this Bill Rs.
Balance Rs.

Signature of Drawing & Disbursing Officer

Countersigned for Rs._______________

FOR USE IN PRE-CHECK UNIT

Pay Rs.

Examined

Accountant Accounts Officer.

FOR USE IN ZONAL ACCOUNTS OFFICE

Admitted Rs.____________

Objected Rs.____________

Reasons for objection :

Auditor Superintendent Gazetted Officer.

 Application for Leave

1. Name of the Applicant.

2. Post held.

3. Department, Office & Section.

4. Pay

5. House Rent Allowance & other compensatory

allowances drawn in the present post.
6. Nature & period of leave applied for and date
from which required.
7. Sundays & holidays, if any, proposed to be
prefixed/suffixed to Leave.
8. Grounds on which the leave is applied for.

9. Date of return from last leave and the nature

and period of that leave.
10. I propose/do not propose to avail myself of
Leave Travel Concession for the block years
___________ during the ensuing leave.
11. Address during the Leave period.

_________________________
Signature of the Applicant

12. Remarks and/or recommendation of the

Controlling Officer.
 CERTIFICATE REGARDING ADMISSIBILITY OF LEAVE

13. Certified that _________________(nature of leave) for ________________(period) from

_______________________ to ______________________ is admissible under Rule _____________
of the Central Civil Services Leave Rules, 1972.

Signature of recommending Officer

14. Remarks / Orders of the authority competent to grant the leave.

Signature of the Sanctioning Authority