7th CPC CEA – Proforma for Re-Imbursement

7th CPC CEA – Proforma for Re-Imbursement

PROFORMA FOR RE-IMBURESMENT OF CHILDREN EDUCATION ALLOWANCE

CLAIM FOR THE ACADEMIC YEAR: 2017-18

I hereby apply for the reimbursement of Children Education Allowance / Hostel Subsidy for my child / children and relevant particulars are furnished below:-

Re-imbursement of Expenditure :-

9. Distance of Hostel of child from residence of employee (in case Hostel Subsidy): NA

10. Amount of CEA / Hostel Subsidy already received up to previous quarter: NIL

11. The Academic year for which CEA / Hostel Subsidy is applied now: 2017-18

12. (a) Whether the child for whom the CEA is applied for is a disabled child : Yes / No
(b) If yes, indicate the nature of disability:
(c) Date of disability certificate:
(d) Indicate the percentage of disability:
13. Whether the Bonafide certificate from Head of Institution has been attached : Yes / No

14. For Hostel Subsidy, the Bonafide certificate from mentioning the amount is attached: NA

15. If Yes at Item No. 14, Amount claimed for Hostel Subsidy: Rs___NA___

16. (a) Certified that I or my wife / husband is / is not a Central Government servant.
(b) Certified that my wife / husband Sri / Smt …………………………………….. is presently working as:…………………………………. in ………………………………………………. and that he / she shall not apply / has not applied for the Children Education Allowance for the child/children mentioned above.
(c) Certified that I or my wife / husband has not claimed this re-imbursement from anyother source and will not claim the same in future.

17. Certified that my child in respect of whom re-imbursement of Children Education Allowance is applied is studying in the School / Jr. College which is recognized and affiliated to Board of Education / University.

18. Certified that I am claiming the CEA in respect of my two eldest surviving children only, The information furnished above are complete and correct and I have not suppressed any relevant information. In the event of any change in the particulars given above which affect my eligibility for reimbursement of Children Education Allowance, I undertake to intimate the same promptly and also to refund excess payments if any made. Further, I am aware that if at any stage the information / documents furnished above is found to be false, I am liable for
disciplinary action.

Date: Apr 18

Place: Goa

(Signature of Govt Servant)

Name: ………………………………………..
Rank : ………………………………………..
P.No.: ……………………………………….

II
COUNTERSIGNED

ICGS Samarth
Goa – 403 803

Date: Apr 18

Source: Confederation