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Get Sample Application For Claiming Refund Of Medical Expenses

Treatment taken from an Authorised Medical Attendant / Hospital. (N.B.- SEPARATE FORM SHOULD BE USED FOR EACH PATIENT) 1. NAME and DESIGNATION of the Government servant (in BLOCK letters) : i) Whether Married or Unmarried : ii) If married, the place where wife/ husband is employed : 2. Office /Division 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 re.

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