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/C’s 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)