FORM STR 29-A

(See rule S.T.R. 4.43 A)

MEDICAL CHARGES REIMBURSMENT FORM

 

Bill No. & Date :__________________†††††††††††††††††††††††††††††††††††††††††††††† Voucher No:_____________

Establishment of __________________†††††††††††††††††††††††††††††††††††††††††††††† Voucher Date:____________

 

 

 

  1.  

Treasury Code††††††††††††††††† :††††††††††††† ††††

 

 

 

 

 

 

8.

Voted/Charged(V/C):

 

 

  1.  

D.D.O. Code†††††††††††††††††††††† :

 

 

 

 

 

 

9.

Demand No.:

 

 

  1.  

Major Head†††††††††††††††††††††††† :

 

 

 

 

 

 

10

Object Code :

 

 

  1.  

Sub Major Head††††††††††††††††† :

 

 

 

 

  1.  

Minor Head†††††††††††††††††††††††† :

 

 

 

 

  1.  

Sub Head/ Scheme††††††††††††† :

 

 

 

  1.  

Plan/ Non Plan (P/L)†††††††††† :

 

 

 

†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† †††††† ††††††††††††††††††††††††††††††††

 

 

 

 

 

 

 

 

(Space for Head A/Cís Stamp)

 

Sr. No.

Name of claimant with designation

AMOUNT

Gross Claim†††† ††††Adv. Adjusted††††† Net Amount

1.

 

2.

 

3.

 

4.

 

5.

 

6.

 

7.

 

8.

 

9.

 

10.

 

11.

 

12.

 

13.

 

14.

 

15.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total (Rs.) ____________________________

†††††††††††††††††† ____________________________

 

 

 

 

 

 

 

 

 

 

 

Certificates

 

1.                  Received the contents of this bill.

2.                  Certified that the amount being drawn in this bill is in accordance with rules and instructions as amended from time to time.

3.                  Certified that cash memoes and essentiality certificate duly signed by competent authority in the case of each officer/ officials are attached.

4.                  Certified that no amounts drawn previously more than 3 months old is lying undisbursed and the amounts drawn 1/2/3 months previous to this date are being refunded as per details given below.

 

Name

Period

Amount

Drawn vide Vr.No.& Date

 

 

 

 

 

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Appropriation

 

Appropriation for (year) _____________ to _____________ Rs. ___________________

 

Deduct Expenditure††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Rs. ___________________

(Including this bill)

 

Balance Available†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Rs. ___________________

 

Passed for Rs. _________(In words Rs.) ______________________________________

 

 

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (Signature of D.D.O.)

 

(Signature of Controlling Officer)

______________________________________________________________________

††††††††††††††††††††††††††††††††††††††††††††††† (For use in Treasury Office)

 

Pay Rs. ________________ (Rupees _______________________________________)

 

 

††††††††††† (Treasury Clerk)†††††††††††††††††††††† (AST)††††††††††††††††††††††††† (Treasury Officer)††††††††††††††††††††

______________________________________________________________________

 

††††††††††††††††††††††††††††††††††††††††††††††† (For use in A.G. Office)

 

Admitted for ††††††††††††††† Rs. _____________________

Objected for ††††††††††††††† Rs. _____________________

Reasons of objection _________________________

 

 

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† (Accounts Officer)†††††††