Reimbursement Claim for Expenses incurred for the month of



Reimbursement Claim for Expenses incurred for the month of _________.

Name: __________________________ HRD No. __________________

Designation _____________________ Car Scheme(‘Y’/’N’) _________

Location __________________________ Cadre______________________

(Amount rounded off to the nearest rupee)

|S.No |Type of Reimbursement |No of supportings | Amount (in Rs.) |

|1 |Conveyance | | |

|2 |Medical Expense | | |

|3 |Children Education | | |

|4 |LTA Claim - (taxable) |Please use separate claim for LTA with | |

| | |bill for claiming of exemption | |

| |Total |0 | |

P.S:

1. Declaration for Conveyance is applicable only for Executives only.

2. Petrol Bills for conveyance reimbursement is to be produced. (who are all eligible for car)

3. Medical bills for reimbursement will be allowed only current year bills.

4. In case you plan to take advance against LTA eligibility you have to specify upfront at the time of taking advance approval amount for which you plan to avail exemption.

5. Conveyance Reimbursement Declaration for Executives :(fill the declaration without fail.)

Certified that I have incurred an amount of Rs.__________ (Rupees ____________________

______________________________ only) towards local conveyance during the month.

No of Kms Travelled ________________ Rate per Km ____________

(filling up of conveyance reimbursement declaration for executives shall be mandatory).

Date: Signature of the employee

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Please number the supporting and keep it in the order of above serial numbers/ nature of expenses claimed.

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