דÖ׍úŸÃÖÖ - 103/Med.

-103

___________________________________´Öë ×−ÖμÖãŒŸÖ ÁÖß/ÁÖß´ÖŸÖß/ãú´ÖÖ¸___________________________________________

¯ÖŸ−Öß/¯Öã¡Ö/¯Öã¡Öß/ ÁÖß _____________________________________________________________________úÖê פüμÖÖ ÖμÖÖ ¯ÖÏ´Ö֝֯֡Ö
Certificate granted to Shri/Smt/Kumari_____________________________________________________________
Wife/Son/Daughter of Shri/Smt/Kumari__________________________________________________employed in
The Office of the Pr. Accountant General (C & R.A.) Gujarat, Ahmedabad.

¯ÖÏ´ÖÖÖ¯Ö¡Ö ‘ú’ CERTIFICATE - ‘A’

(To be completed in the case of patients who are not admitted to hospital for treatment)
ˆ−Ö ¸üÖêÖßμÖÖë êú ´ÖÖ´Ö»Öê´Öë ³Ö¸üÖ •ÖÖμÖê וÖ−Æëü ‡»ÖÖ•Ö êú ×»Ö‹ †Ã¯ÖŸÖÖ»Ö´Öë ³ÖŸÖá ׍úμÖÖ ÖμÖÖ −Ö ÆüÖê
´Öî______________________________________________________________________‡ÃÖ êú «üÖ¸üÖ ¯ÖÏ´ÖÖ×ÖŸÖ ú¸üŸÖÖ ÆæÑü
1. Dr. hereby certify.
(ú) ´Öï−Öê ´Öê¸êü ¯Ö¸üÖ´Ö¿Öá úÖ´Öë______________________________úÖê___________________________êú ¯Ö¸üÖ´Ö¿ÖÔ/¯Ö¸üÖ´Ö¿ÖÖí êú ×»ÖμÖê
¸üÖêÖß êú ×−Ö¾ÖÖÃÖ Ã£ÖÖ−Ö ¯Ö¸ü (ŸÖÖ¸üßÖ ¤üß •ÖÖμÖ)
ºþ.____________¿Ö㻍ú »ÖÖÖμÖÖ †Öî¸ü ¯ÖÏÖ¯ŸÖ ׍úμÖÖ …
(a) That I charged and received Rs. -----------------------------------------for----------------------------------------------------
consolation(s) on------------------------------------------------- my consulting room ----------------------------------------
(date to be given) at the residence of the patient.
†−ŸÖ׿ָüÖ
(Ö) ׍ú ´Öï−Öê ´Öê¸êü ¯Ö¸üÖ´Ö¿Öá úÖ ´ÖêÓ/¸üÖêÖß êú ×−Ö¾ÖÖÃÖãÖÖ−Ö ¯Ö¸ü_____________________________úÖê ‡−™ÒüÖ´ÖÃŒμÖã»Ö¸ü ‡−•ÖꌿÖ−Ö êú ¯ÖϲÖ−¬Ö êú ×»Ö‹
(ŸÖÖ׸üÖ פü •ÖÖμÖ) †¬Ö Ÿ¾Ö“ÖßμÖ
ºþ. _____________¿Ö㻍ú »ÖÖÖμÖÖ †Öî¸ü ¯ÖÏÖ¯ŸÖ ׍úμÖÖ …
(b) That I charged and received Rs. for administering
intra - venous - ___________________________________________
intra - muscular Injection on_____________________at my consulting room/at the residence of the
patient.
Sub - cutancous (date to be given)
(Ö) ׍ú פü‹ Ö‡Ô ‡Ó•ÖꌿÖ−Ö ¸üÖêÖ Ö´ÖŸÖÖ μÖÖ ¸üÖêÖ-×−Ö¸üÖê¬Ö êú ×»Ö‹ £Öê / −ÖØÆü £Öê …
(c) That the injections administered were/were not for immunising or prophylactic purposes.
(‘Ö) ׍ú ¸üÖêÖß ‡»ÖÖ—Ö êú ×»Ö‹ _________________________________________†Ã¯ÖŸÖÖ»Ö/´Öê¸êü ¯Ö¸üÖ´Ö¿Öá ºþ´Ö ´Öë ¸üÆüÖ Æîü, †Öî¸ü ׍ú ‡ÃÖ
ÃÖ´²ÖÓ¬Ö´Öë ´Öê¸êü −ÖãÃ֏Öê´Öë ¤üß Ö‡Ô ×−Ö´−Ö×»Ö×ÖŸÖ †ÖîÂÖ¬ÖêÓ ¸ü֐ê Öß úß ÆüÖ»ÖŸÖ ´Öë ÃÖã¬ÖÖ¸ü »ÖÖ−Öê êú ×»Ö‹/ÖÓ³Ö߸ü ºþ¯ÖÃÖê Ö¸üÖ²Ö ÆüÖ−ê Öê ÃÖê ¸üÖêú−Öê êú ×»Ö‹ †×−Ö¾ÖÖμÖÔ £Öß, μÖê
†ÖîÂÖ¬Öê_____________________________†Ã¯ÖŸÖÖ»Ö´Öë ¯ÖÏÖ‡Ô¾Öê™ü ¸üÖêÖßμÖÖë úÖê ¤êü−Öê êú ×»Ö‹ Ùü֍ú −ÖÆüà úß •ÖÖŸÖß †Öî¸ü ˆÃÖ´ÖêÓ μÖê ¯Öê™ëü™ü (‡úÖμÖŸÖ)
(†Ã¯ÖŸÖÖ»Ö úÖ −ÖÖ´Ö)
μÖÖêÖ ¿ÖÖ×´Ö»Ö −ÖÆüß Æîü … וÖ−֍êú ×»Ö‹ ÃÖ´ÖÖ−Ö ×“Ö׍úŸÃÖÖ ´ÖÖ−֍êú ÃÖßÖê ¦ü¾μÖ ˆ¯Ö»Ö²¬Ö Æîü … −ÖÆüßÓ ¾Öê μÖÖêÖ •Öß ´Ö滟Ö: ÖÖª ÁÖéӐÖÖ¸ü ÃÖִ֐ÖÏß †£Ö¾ÖÖ ×−Ö:ÃÖӍÎúִ֍ú
Æîü …
(d) That the patient has been under treatment at__________hospital/my consulting room, and that
the under mentioned medicines prescribed by me in this connection were essential for the
recovery/prevention of serious deterioration in the condition of the patient. The medicines are
not stocked in the ___________________________________________________________________
(Name of Hospital)
for supply to private patients and do not include proprietary preparations for which cheaper
substances of equal therapeutic value are available nor preparations which are primarily which
are primarily foods, toilets or disinfectants.

Îú.ÃÖÓ. †ÖîÂÖ¬ÖÖê úÖ −ÖÖ´Ö/NAME OF MEDICINES úà´ÖŸÖ/Price

Sr.No. Rs. Ps.
1.
2.
3.
4.
5.
6.
7.
8.
Total
(›ü) ׍ú ¸üÖêÖß_______________________________________ÃÖê ¯Öß×›üŸÖ Æîü/£ÖÖ Öî¸ü_______________ÃÖê__________________
ŸÖú ´Öê¸êü ‡»ÖÖ•Ö ´Öë Æîü/£ÖÖ …
(e) That the patient is/was suffering from---------------------------------------------------------------------------
and is/was under my treatment from--------------------------to------------------------------------------------
(“Ö) ׍ú ¸üÖêÖߍúÖê ¯ÖÆêü»Öê μÖÖ ²ÖÖ¤ü ´Öë ׯÖÏ-−ÖÖ™ü»Ö ÃÖÖ¸ü¾ÖÖ¸ü −Ö×ÆüÓ ×¤ü Æüî/−ÖØÆü ¤üß £Öß …
(f) That the patient is/was not given pre-natal or post-natal treatment.
(”û) ׍ú וÖ−Ö ‹ŒÃÖ-¸êü ¯ÖÏμÖÖêÖ¿ÖÖ»ÖÖ •ÖÖÓ“Ö †Öפü êú ×»Ö‹-----------------------------------------------------------------------------------
ºþ¯ÖμÖê Ö“ÖÔ ×ú‹ £Öê ¾Öê †Ö¾Ö¿μ֍ú £Öê †Öî¸ü ¾Öê ´Öê¸üß ÃÖ»ÖÖÆü ÃÖê_______________________________________________________
´Öë ׍ú‹ ÖμÖê £Öê … (†Ã¯ÖŸÖÖ»Ö μÖÖ ¯ÖÏμÖÖêÖ¿ÖÖ»ÖÖ úÖ −ÖÖ´Ö)
(g) That the X-ray, laboratory tests etc. for which an expenditure of Rs.---------was incurred were necessary and
were undertaken on my advice at ______________________________________________________________
Name of Hospital or Laboratory
(•Ö) ׍ú ´Öï−Öê ¸ü֐ê Öß úÖê ×¾Ö¿ÖêÂÖ ¯Ö¸üÖ´Ö¿ÖÔ êú ×»Ö‹ ›üÖò._________________________êú ¯ÖÖÃÖ ³Öê•ÖÖ £ÖÖ___________________________
†Öî¸ü_______________________________úÖ ×−ÖμÖ´ÖÖë êú †−ÖãÃÖÖ¸ü μÖ£ÖÖ ¯Öê×ÖŸÖ †Ö¾Ö¿μ֍ú †−Öã´ÖÖê¤ü−Ö ¯ÖÏÖ¯ŸÖ ú¸ü פüμÖÖ ÖμÖÖ £ÖÖ …
(¸üÖ•μÖ êú ´ÖãμÖ ¯ÖÏ¿ÖÖÃÖ×−֍ú דÖ׍úŸÃÖÖ †×¬ÖúÖ¸üß úÖ −ÖÖ´Ö)
(h) That referred the patient to Dr._______________________________________________________for specialist
consultation and that the necessary approval of the _______________________________________________
as required under the rules, was obtained.
Name of the Chief Administrative Medical Officer
(™ü) ׍ú ¸üÖêÖß úÖê †Ã¯ÖŸÖÖ»Ö ³ÖŸÖá úß •Öºþ¸üŸÖ £Öß/−ÖÆüà £Öß …
(i) That the patient did not require hospitalization.
required

ŸÖÖ¸üßÖ ¯ÖϳÖÖ¸üß ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß êú

Dated ÆüßÖցָü ¯Ö¤ü−ÖÖ´Ö †Öî¸ü μÖÖêμÖŸÖÖ ×•ÖÃÖ
†Ã¯ÖŸÖÖ»Ö/¤ü¾Ö֏ÖÖ−ÖÖ ´Öë úÖ´Ö ú¸üŸÖÖ ÆüÖê ˆÃÖ úÖ −ÖÖ´Ö
Signature Designation and Degree of the
Medical Officer, and Hospital/Dispensary
to which attached.

N.B. :- Æü¸ü •ÖÖÆü ¯Ö¸ü •ÖÆüÖÑ ¯ÖÏ´ÖÖÖ¯Ö¡Ö »Ö֐Öã −ÖÆüà ÆüÖêŸÖÖ ÆüÖê, ¯ÖÏ´ÖÖÖ¯Ö¡Ö (ú) †×−Ö¾ÖÖμÖÔ Æîü †Öî¸ü ÃÖÖ£Ö´Öë ³Ö¸üÖ •ÖÖμÖ
דÖ׍úŸÃÖÖ †×¬ÖúÖ¸üß «üÖ¸üÖ ×−֍úÖ»Ö ×¤üμÖÖ •ÖÖμÖ … Certificate (A0 is compulsory and must
Certificates not applicable should be struck off be filled in
by the Medical Officer in all cases
 דÖ׍úŸÃÖÖ-97 / MED-97
êú−¤üßμÖ ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üßμÖÖë ŸÖ£ÖÖ ˆ−֍êú ¯Ö׸ü¾ÖÖ¸ü úß ›üÖŒ™ü¸üß úÖ ¯Ö׸ü“ÖμÖÖÔ †Öî¸ü/μÖÖ ‡»ÖÖ•Ö ¯Ö¸ü Æãü‹ ›üÖŒ™ü¸üß Ö“ÖÔ úß ¾ÖÖ¯ÖÃÖß ŸÖ£ÖÖ ¤üÖ¾ÖÖ
ú¸ü−Öê úÖ †Ö¾Öê¤ü−Ö-¯Ö¡Ö
Form of application for claiming refund of medical expense incurred in connection with medical attendance
And /or treatment of Central Government Servants and their families.
¬μÖÖ−Ö ×¤üו֋ - Æü¸ü ¸ü֐ê Öß êú ×»Ö‹ †»ÖÖ ±úÖ´ÖÔ ³Ö¸üÖ •ÖÖ−ÖÖ “ÖÖ×Æü‹ …
N.B. Separate form should be used for each patient.
1. ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß úÖ −ÖÖ´Ö †Öî¸ü ¯Ö¤ü … (ÃÖÖ±ú †Ö¸üÖê ´Öë)
Name and designation of the Government Servant (In block letters)
2. ׍úÃÖ úÖμÖÖÔ»ÖμÖ ´Öë úÖ´Ö ú¸ü ¸üÆüÖ Æîü …
Office in which employed.
3. †Ö¬ÖÖ¸ü´Öæ»Ö ×−ÖμÖ´ÖÖë ´Öë ¾ÖêŸÖ−Ö úß ¤üß Ö‡Ô ¯Ö׸ü³ÖÖÂÖÖ êú †−ÖãÃÖÖ¸ü ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß úÖ ¾ÖêŸÖ−Ö, μÖפü
†−μÖ úÖê‡Ô ˆ¯Ö»ÖÛ²¬ÖμÖÖÓ ÆüÖê ŸÖÖê ˆ−Æêü †»ÖÖ ÃÖê פüÖÖ‡Ô •ÖÖ−ÖÖ “ÖÖ×Æü‹ …
Pay of the Government Servant as defined in the Fundamental Rules and any other
employments, which should be shown separately.
4. −ÖÖêú¸üß úÖ Ã£ÖÖ−Ö … Place of Duty
5. ×−Ö¾ÖÖÃÖ úÖ ¾ÖÖßÖ׾֍ú ¯ÖŸŸÖÖ …
Actual residential address.
6. ¸ü֐ê Öß úÖ −ÖÖ´Ö †Öî¸ü ú´ÖÔ“ÖÖ¸üß ÃÖê ˆÃ֍úÖ ÃÖÓ²ÖÓ¬Ö …
Name of the patient and his/her relationship to the Government servant.
¬μÖÖ−Ö ×¤üו֋ : μÖפü ²Öß´ÖÖ¸ü ²Ö““ÖÖ ÆüÖê ŸÖÖê ˆÃ֍úß ˆ´Ö¸ü ³Öß ×»ÖÖß •ÖÖ‹ …
N.B. In the case of the children state age also.
7. ¸ü֐ê Öß ×úÃÖ Ã£ÖÖ−Ö ¯Ö¸ü ²Öß´ÖÖ¸ü ¯Ö›üÖ … Place at which the patient fell ill.
8. ¤üÖ¾Öê úß ¸üú´Ö úÖ ²μÖÖî¸üÖ … Details of the amount claimed.
(i) ›üÖŒ™ü¸üß ¯Ö׸ü“ÖμÖÖÔ / MEDICAL ATTENDANCE
(i) ×−Ö´−Ö×»Ö×ÖŸÖ ²ÖÖŸÖÖë úÖ ×−Ö¤ìü¿Ö ú¸üŸÖê Æãü‹ ¯Ö¸üÖ´Ö¿ÖÔ úß ±úßÃÖ
Fees for counsultation indicating -
(ú) וÖÃÖ ×“Ö׍úŸÃÖÖ - †×¬ÖúÖ¸üß ÃÖê ¯Ö¸üÖ´Ö¿ÖÔ ×úμÖÖ ÖμÖÖ Æîü ˆÃ֍úÖ −ÖÖ´Ö †Öî¸ü ¯Ö¤ü ŸÖ£ÖÖ ˆÃÖ †Ã¯ÖŸÖÖ»Ö μÖÖ †ÖîÂÖ¬ÖÖ»ÖμÖ úÖ −ÖÖ´Ö
וÖÃÖê ¾ÖÆü †×¬ÖúÖ¸üß ÃÖÓ²ÖÓ¨ü Æîü …
(a) the name and designation of the medical officer consulted and the hospital or dispensary
to which attached.
(Ö) ׍úŸÖ−Öß ²ÖÖ¸ü †Öî¸ü ׍úÃÖ ŸÖÖ¸üßÖ úÖê ¯Ö¸üÖ´Ö¿ÖÔ ×»ÖμÖÖ ÖμÖÖ †Öî¸ü Æü¸ü ¯Ö¸üÖ´Ö¿ÖÔ êú ×»Ö‹ ׍úŸÖ−Öß ±úßÃÖ ×¤ü Ö‡Ô …
(b) the number and dates of consultation and the fee paid for each consultation.
(Ö) ׍úŸÖ−Öß ÃÖæ‡ÔμÖÖ ×ú−Ö ×ú−Ö ŸÖÖ¸üߏÖÖë úÖê »ÖÖß †Öî¸ü Æü¸ü ÃÖæ‡Ô êú ×»Ö‹ ׍úŸÖ−Öß ±úßÃÖ ¤êü−Öß ¯Ö›üß …
(c) the number and date of injections and the fee paid for each injection.
(‘Ö) ŒμÖÖ ¯Ö¸üÖ´Ö¿ÖÔ †Öî¸ü / μÖÖ ÃÖæ‡μÔ ÖÖÓ †Ã¯ÖŸÖÖ»Ö ´Öë »Öß Ö‡Ô μÖÖ ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß êú ¯Ö¸üÖ´Ö¿ÖÔ úÖ ´Öë μÖÖ ¸ü֐ê Öß êú ×−Ö¾ÖÖÃÖ
ãÖÖ−Ö ¯Ö¸ü …
(ii) whether consultaion and/or injections were held at the hospital, at the consulting
room of the medical officer or at the residence of the patient.
(ii) ¸ü֐ê Ö úÖ ×−Ö¤üÖ−Ö ú¸üŸÖê ÃÖ´ÖμÖ ×ú‹ Ö‹ ׾֍éú×ŸÖ - ¾Öî–ÖÖ×−֍ú, ן־Ö֝Öã - ¾Öî–ÖÖ×−֍ú, ×¾Ö׍ú¸üÖ ¾Öî–ÖÖ×−֍ú †Öî¸ü ‹ÃÖê Æüß ¤æüÃÖ¸êü
¯Ö¸ü߁֝ÖÖë úÖ Ö“ÖÔ ×»Ö׏֋ †Öî¸ü ×−Ö´−Ö×»Ö×ÖŸÖ ²ÖÖŸÖë ²ÖŸÖ»ÖÖ‡‹ …
Charges for pathological, bacteriological, radiological or other similar tests
Undertaken during diagnosis indicating.
(ú) †Ã¯ÖŸÖÖ»Ö μÖÖ ¯ÖÏμÖÖêÖ¿ÖÖ»ÖÖ úÖ −ÖÖ´Ö •ÖÆüÖÑ ¯Ö׸üÖÖ Æãü‹ …
(a) the name ot the hospital or laboratory where the test were undertaken.
(Ö) ŒμÖÖ μÖê ¯Ö׸üÖÖ ¯ÖÏÖ׬֍éúŸÖ - דÖ׍úŸÃÖÖ ¯Ö׸ü“ÖÖ¸üú úß ÃÖ»ÖÖÆü ¯Ö¸ü Æãü‹, μÖפü ÆüÖÓ ŸÖÖê ˆÃ֍úÖ ¯ÖÏ´Ö֝Ö-¯Ö¡Ö ‡Ã֍êú ÃÖÖ£Ö »ÖÖÖ‹Ó …
(b) whether the tests were undertaken on the advice of the authorized medical attendant; if
so, a certificate to the effect should be attached.
(Ö) ²ÖÖ•ÖÖ¸ü ÃÖê Ö¸üߤüß Æãü‡Ô ¤ü¾ÖÖ†Öë úÖ ´Öæ»μÖ …
(c) cost of medicines, purchased from the market.
(¤ü¾ÖÖ†Öêê úß ÃÖæדÖ, −֍ú¤ü-¯Ö¡Ö †Öî¸ü †ŸμÖÖ¾Ö¿μ֍úŸÖÖ ¯ÖÏ´Ö֝Ö-¯Ö¡Ö ÃÖÖ£Ö »ÖÖÖ‹Ó)
(List of medicines, cash memos and the essentiality certificates should be attached)
†Ã¯ÖŸÖÖ»Öß ‡»ÖÖ•Ö HOSPITAL TREATMENT –
†Ã¯ÖŸÖ¯Ö»Ö úÖ −ÖÖ´Ö / Name of the Hospital
†Ã¯ÖŸÖÖ»Öß ‡»ÖÖ•Ö êú Ö“ÖÔ-×−Ö´−Ö×»Ö×ÖŸÖ Ö“ÖÖí úÖ †»ÖÖ-†»ÖÖ ×−Ö¤ìü¿Ö ׍úו֋ …
Charges for hospital treatment, indicating separately the charges for -
(i) †Ö¾ÖÖÃÖ / Accommodation
(μÖÆü ׻֏Öê ׍ú ŒμÖÖ †Ö¾ÖÖÃÖ ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß êú ¾ÖŸÖÔ´ÖÖ−Ö ¾ÖêŸÖ−Ö μÖÖ Æîü×ÃÖμÖŸÖ êú †−Öãºþ¯Ö ×Æü £ÖÖ, μÖפü −Ö×Æü ŸÖÖê ‡ÃÖ †Ö¿ÖμÖ
úÖ ‹ú ¯ÖÏ´Ö֝Ö-¯Ö¡Ö ¤ëü וÖÃÖ ¯ÖύúÖ¸ü úÖ †Ö¾ÖÖÃÖ êú ×»Ö‹ ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß Æüú¤üÖ¸ü £ÖÖ, ¾Ö× ˆ¯Ö»Ö²¬Ö −ÖÆüß £ÖÖ … )
(State whether is / was according to the status or pay of the Government servant and incase
where the accommodation is higher than the status the Government servant, a certificate
should be attached to the effect that accommodation to which he was entitled was not available.)
(ii) Öã¸ü֍ú / Diet
(iii) ¿Ö»μÖ׍ÎúμÖÖ μÖÖ ›üÖŒ™ü¸üß ‡»ÖÖ•Ö μÖÖ ¯Ö׸ü¸üÖê¬Ö …
Surgical operation or medical treatment or confinement
(iv) ׾֍éú×ŸÖ ¾Öî–ÖÖ×−֍ú, •Öß¾Ö֝Öã-¾Öî–ÖÖ×−֍ú, ׾֍ú߸üÖ-¾Öî–ÖÖ×−֍ú μÖÖ †−μÖ ¯Ö׸üÖÖ μÖÆü ²ÖÖŸÖ ³Öß ²ÖŸÖ»ÖÖ‡Ô •ÖÖ‹ …
Pathological, bacteriological, radiological or other similar tests indicating-
(ú) †Ã¯ÖŸÖÖ»Ö μÖÖ ¯ÖÏμÖ֐ֿÖÖ»ÖÖ úÖ −ÖÖ´Ö ×•ÖÃÖ ´Öë ¯Ö¸üßÖÖ Æãü‹ …
(a) The name of the hospital or laboratory at which undertaken.
(Ö) ŒμÖÖ ¾Öê ¯Ö¸üßÖÖ úÖμÖÔ³ÖÖ¸üß ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß úß ÃÖ»ÖÖÆü ÃÖê †Ã¯ÖŸÖÖ»Ö ´Öë Æãü‹ ? μÖפü ÆüÖÓ, ŸÖÖê ‡ÃÖ †Ö¿ÖμÖ úÖ ¯ÖÏ´Ö֝Ö-¯Ö¡Ö ÃÖÖ£Ö »ÖÖÖ‹Ó …
(b) Whether, undertaken on the advice of the medical officer incharge of the case at the hospital,
if so, a certificate to that effect should be attached.
(v) ¤ü¾ÖÖ‹Ó / Medicines
(vi) ×¾Ö¿ÖêÂÖ ¤ü¾ÖÖ‹Ó / Special Medicine
(vii) (¤ü¾ÖÖ†Öë úß ÃÖæÛ““Ö, −֍ú¤ü ¯Ö¡Ö †Öî¸ü †ŸμÖÖ¾Ö¿μ֍ú ¯ÖÏ´Ö֝Ö-¯Ö¡Ö ³Öß »ÖÖÖ‹Ó … )
(List of medicines, cash memo and essentiality certificate should be attached)
(viii) ÃÖÖ¬ÖÖ¸üÖ ˆ¯Ö“ÖμÖÖÔ / Ordinary nursing
×¾Ö¿ÖêÂÖ ˆ¯Ö“ÖμÖÖÔ μÖÖ−Öß ¸üÖêÖß êú ×»Ö‹ דֿÖêÂÖ ºþ¯Ö ÃÖê −ÖÃÖÔ »ÖÖÖ‡Ô Ö‡Ô / μÖÆü ׻֏Öë ׍ú •ÖÖê †Öî¸ü −ÖÃÖÔ »ÖÖÖ‡Ô Ö‡Ô ˆ−֍êú ×»Ö‹
†Ã¯ÖŸÖÖ»Ö ´Öë ‡Ã֍êú úÖμÖÔ³ÖÖ¸üß ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß ÃÖ»ÖÖÆü ¤üß £Öß μÖÖ ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß μÖÖ ¸üÖêÖß úß ¯ÖÏÖ£ÖÔ−ÖÖ ¯Ö¸ü ×−ÖμÖãÛŒŸÖ úß
Ö‡Ô … ¯ÖÆü»Öß ¾ÖÖ»Öß ÛãÖ×ŸÖ ÆüÖ−ê Öê ¯Ö¸ü úÖμÖÔ³ÖÖ¸üß úÖ ¯ÖÏ´Ö֝Ö-¯Ö¡Ö ÃÖÖ£Ö ´Öë »ÖÖÖμÖÖ •ÖÖ−ÖÖ “ÖÖ×Æü‹ וÖÃÖ ¯Ö¸ü דÖ׍úŸÃÖÖ †×¬ÖÖú êú
¯ÖÏ×ŸÖ ÆüßÖցָü ³Öß ÆüÖë …
Special nursing i.e. nurses specially engaged for the patient. State whether they were employed
On the advice of the medical officer-in-charge of the case at the hospital or at the request of the
Government servant or patient. In the former case, a certificate from the medical officer-in-charge
of the case, countersigned by the Medical Superintendent of the hospital should be attached.
(ix) ‹´²Öã»ÖëÃÖ Ö“ÖÔ (úÆüÖÓ êú úÆüÖÓ ŸÖú μÖÖ¡ÖÖ úß Ö‡Ô μÖÆü ׻֏Öê)
Ambulance charges (State the Journey - to and from undertaken)
(x) †Öî¸ü ¤æüÃÖ¸êü Ö“ÖÔ μÖÖ−Öß ×²Ö•Ö»Öß úß ¸üÖê¿Ö−Öß, ¯ÖӏÖÖ, Æüß™ü¸ü ¾ÖÖŸÖÖ−Öããú»Ö−Ö †Öפü êú Ö“Öì … μÖÆü ³Öß ×»ÖÖê úß μÖÆü ÃÖã×¾Ö¬ÖÖ‹Ó
ÃÖÖ¬ÖÖ¸üÖŸÖ: ÃÖ³Öß ¸üÖêאÖμÖÖë úÖê ¤üß •ÖÖŸÖß Æîü †Öî¸ü ¸ü֐ê Öß úß ×¾Ö¿ÖêÂÖ ‡“”ûÖ ¯Ö¸ü úÖê‡Ô “Öß•Ö −ÖÆüß ¤üß Ö‡Ô …
Any other charges, e.g., charges for electric light, fan, heater, air-conditioning etc. State also
Whether the facilities are normally provided to all patients and no choice was left to the patient.
×™ü¯¯ÖÖß : 1. μÖפü ³ÖÖ¸üŸÖ ´ÖÓ¡Öß ÃÖê¾ÖÖ ×“Ö׍úŸÃÖÖ ¯Ö׸ü“ÖμÖÖÔ (‹´Ö.‹.) ×−ÖμÖ´ÖÖ¾Ö»Öß 1938 êú ×−ÖμÖ´Ö 3 úê †−ÖãÃÖÖ¸ü μÖÖ ëúצüμÖ ÃÖê¾ÖÖ ×“Ö׍úŸÃÖÖ ¯Ö׸ü“ÖμÖÖÔ (‹´Ö.‹.) ×−ÖμÖ´ÖÖ¾Ö»Öß 1944 êú ×−ÖμÖ´Ö
7 êú †−ÖãÃÖÖ¸ü μÖפü ‡»ÖÖ•Ö ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß êú ×−Ö¾ÖÖÃÖ Ã£ÖÖ−Ö ¯Ö¸ü Æüß Æãü†Ö ÆüÖê ŸÖÖê ˆÃ֍úÖ ×¾Ö¾Ö¸üÖ ¤êü †Öî¸ü ‡−Ö ×−ÖμÖ´ÖÖë êú †−ŸÖÖÔŸÖ ¯ÖÏÖ׬֍éúŸÖ דÖ׍úŸÃÖÖ-¯Ö׸ü“ÖÖ¸üú úÖ
¯ÖÏ´ÖÖÖ¯Ö¡Ö ÃÖÖ£Ö ´Öë »ÖÖÖ‹Ó …
If the treatment was received by the Government servant at his residence under rule 3 of the Secretary of State Service (M.A.),
Rules or Rule 7 of the C.S.(M.A.) Rules 1938, or Rules 1944 give particulars of such treatment and attach a certificate from the
authorised medical attendant as required by these rules.
2. μÖפü ‡»ÖÖ•Ö ÃÖ¸üúÖ¸üß †Ã¯ÖŸÖÖ»Ö êú †»ÖÖ¾ÖÖ ×úÃÖß †Öî¸ü •ÖÖÆü Æãü†Ö Æîü ŸÖÖê ˆÃ֍úÖ †Ö¾Ö¿μ֍ú ×¾Ö¾Ö¸üÖ ¤êÓ †Öî¸ü ¯ÖÏÖ׬֍éúŸÖ דÖ׍úŸÃÖÖ ¯Ö׸ü“ÖÖ¸üú úÖ ‡ÃÖ †Ö¿ÖμÖ úÖ ¯ÖÏ´Ö֝Ö-
¯ÖÏ¡Ö¤êü ׍ú †¯Öê×ÖŸÖ ‡»ÖÖ•Ö úß ¾μÖ¾ÖãÖÖ ×úÃÖß ×−֍ú™üŸÖ´Ö ÃÖ¸üúÖ¸üß †Ã¯ÖŸÖÖ»Ö ´Öë −ÖÆüß ÆüÖê Ã֍úŸÖß £Öß …
If treatement was received at a hospital other than a Government Hospital, necessary details and the dertificate of the
authorised medical attendant that the requisite treatment was not available in any nearest Government Hospital should be
furnished
(III) ×¾Ö¿ÖêÂÖ–ÖÖ ¯Ö¸üÖ´Ö¿ÖÔ - CONSULTATION WITH SPECIALIST
¯ÖÏÖ׬֍éúŸÖ דÖ׍úŸÃÖÖ - ¯Ö׸ü“Öֻ֍ú êú †×ŸÖ׸üŒŸÖ ׍úÃÖß †Öî¸ü ×¾Ö¿ÖêÂÖ–Ö μÖÖ ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß úÖ ¯Ö¸üÖ´Ö¿ÖÔ »Öê−Öê êú ×»Ö‹ ¤üß
Ö‡Ô ±úßÃÖ †Öî¸ü −Öß“Öê ׻֏Öß ²ÖÖŸÖêÓ ²ÖŸÖ»ÖÖ‡Ô •ÖÖ‹Ó …
Fees paid to a specialist or a medical officer other than the authorized medical attendant, indicating-
(ú) ˆÃÖ ×¾Ö¿ÖêÂÖ–Ö μÖÖ ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß úÖ −ÖÖ´Ö ×•ÖÃ֍úÖ ¯Ö¸üÖ´Ö¿ÖÔ ×»ÖμÖÖ ÖμÖÖ ÆüÖê †Öî¸ü ¾ÖÆü ×¾Ö¿ÖêÂÖ–Ö μÖÖ ×“Ö׍úŸÃÖÖ-†×¬ÖúÖ¸üß ×úÃÖ
†Ã¯ÖŸÖÖ»Ö ´Öë ÃÖê²Öê×¬ÖŸÖ Æîü …
(a) the name and designation ot the specialist or medical officer consulted and the hospital to which attached.
(Ö) ׍úŸÖ−Öß ²ÖÖ¸ü †Öî¸ü ׍ú−Ö ŸÖÖ¸üߏÖÖë úÖê ¯Ö¸üÖ´Ö¿ÖÔ ×»ÖμÖÖ ÖμÖÖ †Öî¸ü Æü¸ü ¯Ö¸üÖ´Ö¿ÖÔ êú ×»Ö‹ ׍úŸÖ−Öß ±úßÃÖ ¤üß Ö‡Ô ?
(b) Number and dates of consultations and the fee charged for each consultation.
(Ö) ŒμÖÖ ¯Ö¸üÖ´Ö¿ÖÔ ×¾Ö¿ÖêÂÖ–Ö μÖÖ ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß êú ¯Ö¸üÖ´Ö¿ÖÔ úÖ ´Öë ×»ÖμÖÖ ÖμÖÖ μÖÖ, †Ã¯ÖŸÖÖ»Ö ´Öë †£Ö¾ÖÖ ¸ü֐ê Öß êú ×−Ö¾ÖÖÃÖ ¯Ö¸ü …
(c) Whether consultation was held at the hospital at the consulting room of the specialist or
medical officer or at the residence of the patient.
(‘Ö) ŒμÖÖ ×¾Ö¿ÖêÂÖ–Ö μÖÖ ×“Ö׍úŸÃÖÖ †×¬ÖúÖ¸üß úß ÃÖ»ÖÖÆü ¯ÖÏÖ׬֍éúŸÖ דÖ׍úŸÃÖÖ ¯Ö׸ü“ÖÖ¸üú úß ¸üÖμÖ ÃÖê »Öß Ö‡Ô £Öß †Öî¸ü ¯ÖÏÖ−ŸÖ êú
´ÖãμÖ ¯ÖÏ¿ÖÖÃÖ×−֍ú-דÖ׍úŸÃÖÖ †×¬ÖúÖ¸üß úÖ ¯Öæ¾ÖÔ Ã¾Öߍéú×ŸÖ ‡Ã֍êú ×»ÖμÖê ¯ÖÏÖ¯ŸÖ ú¸ü »Öß Ö‡Ô £Öß … μÖפü ÆüÖÓ, ŸÖÖê ‡Ã֍êú ×»Ö‹
¯ÖÏ´ÖÖÖ¯Ö¡Ö »ÖÖÖ‹Ó …
(d) Whether the specialist or medical officer was consulted on the advice of the authorised
medical attendant and the prior approval of the Chief Administrative Medical Officer of the
State was obtained, if so, a certificate to that effect should be attaced.
9. ãú»Ö ׍úŸÖ−Öß ¬Ö−Ö¸üÖ×¿Ö úÖ ¤üÖ¾ÖÖ Æîü … ºþ.
Total amount claimed Rs.
10. .............úÖê ×»ÖμÖÖ ÖμÖÖ †ÖÏß´Ö ¬Ö−Ö ‘Ö™üÖ ú¸ü ºþ.
Less advance taken on... Rs.
11. ¤üÖ¾Öê úß ¿Öã¨ü ¸üú´Ö ºþ.
Net amount claimed Rs.
12. ÃÖӻ֐−Ö ¯Ö¡ÖÖë úß ÃÖæ×“Ö -
List of encloseers -
‡ÔÃÖ ‘ÖÖêÂ֝ÖÖ ¯Ö¸ü ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß ÆüßÖցָü ú¸ëü :/ DICLARATION TO BE SIGNED BY GOVERNMENT SERVANT
´Öë ‘ÖÖê×ÂÖŸÖ ú¸üŸÖÖ ÆæÓü ׍ú ‡ÃÖ ¯ÖÏÖ£ÖÔ−ÖÖ ¯Ö¡Ö ´ÖêÓ ×¤üμÖÖ ÖμÖÖ ²ÖμÖÖ−Ö ´Öê¸üß •ÖÖ−֍úÖ¸üß †Öî¸ü ×¾ÖÀ¾ÖÖÃÖ êú †−ÖãÃÖÖ¸ü šüߍú Æîü †Öî¸ü וÖÃÖ ¾μÖÛŒŸÖ êú ˆ¯Ö¸ü דÖ׍úŸÃÖÖ ¾μÖμÖ ×ú‹ Ö‹ Æîü, μÖÆü ¯ÖæÖÔŸÖ: ´Öê¸êü ˆ¯Ö¸ü
†Ö×ÁÖŸÖ Æîü …
I hereby declare that the statements in this application are true to the best of my knowledge and belief and that the person for
whom medical expenses were incurred is wholly dependent upon me.
ŸÖÖ¸üßÖ / Date

ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß êú ÆüßÖցָü †Öî¸ü úÖμÖÖÔ»ÖμÖ ×•ÖÃÖ ´Öë ¾ÖÆü úÖ´Ö ú¸ü ¸üÆüÖ Æîü
Signature of the Government Servant and office to which attached
 †−Öã²Ö¬Ö ‘Ö’
ANNEXURE ‘B’
μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ úß ¯Öê¿ÖÖß úÖ †Ö¾Öê¤ü−Ö
APPLICATION FOR ADVANCE OF TRAVEL CONCESSION
(×™ü¯¯ÖÖß : †Ö¾Öê¤ü−Ö, ”ãû™ü™üß ¯ÖÏÖ¸Óü³Ö ÆüÖê−Öê êú 10 פü−Ö ¯ÖÆü»Öê ãÖÖ¯Ö−ÖÖ †−Öã³ÖÖÖ ´Öë ¯ÖÆãüÓ“Ö •ÖÖ−ÖÖ “ÖÖ×Æü‹)
(NOTE : The application should reach Establishment Section 10 days in advance ot the commencement of leave)

1. −ÖÖ´Ö †Öî¸ü ¯Ö¤ü−ÖÖ´Ö ___________________________

Name and Designation

2. †−Öã³ÖÖÖ ___________________________
Section

3. ¾ÖêŸÖ−Ö ___________________________
Pay

4. ´ÖÆüÖÖ‡Ô ³Ö¢ÖÖ ___________________________

Dearness Pay

5. †Ã£ÖμÖß Æïü μÖÖ Ã£ÖÖμÖß μÖפü †Ã£ÖÖμÖß Æïü, ŸÖÖê ŒμÖÖ ×úÃÖß Ã£ÖÖμÖß ÃÖ¸üúÖ¸üß _______________________

ú´ÖÔ“ÖÖ¸üß «üÖ¸üÖ ×¾Ö×¬Ö¾ÖŸÖ ³Ö¸üÖ ÖμÖÖ ¯ÖÏןֳÖæ ²ÖÓ¬Ö¯Ö¡Ö ÃÖӻ֐−Ö ×úμÖÖ ÖμÖÖ Æîü …
¯ÖÏןֳÖæ×ŸÖ ÆüÖ−ê Öê ¾ÖÖ»Öê ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß êú −ÖÖ´Ö úÖ ˆ»»ÖêÖ ú¸ëü …
Whether temporary or permanent: if temporary whether the
surety bond duly filled in by a permanent Govt. servant
is attached. State the name of servant who stood surety.

6. ŒμÖÖ ¯Öê¿ÖÖß †¯Ö»Öê ×»Ö‹ μÖÖ ¯Ö׸ü¾ÖÖ¸ü êú ×»Ö‹ μÖÖ †¯Ö−Öê †Öî¸ü ¯Ö׸ü¾ÖÖ¸ü ¤üÖ−ê ÖÖë êú ___________________________
×»Ö‹ “ÖÖ×Æü‹ …
whether the advance is for self or family self and family.

7. μÖÖ¡ÖÖ ¯ÖÏÖ¸Óü³Ö ú¸ü−Öê úß ¯ÖÏßÖÖ×¾ÖŸÖ ŸÖÖ¸üßÖ †Öî¸ü ¯Ö׸ü¾ÖÖ¸ü êú ´ÖÖ´Ö»Öê ´Öë ´ÖãμÖÖ»ÖμÖ ___________________________
ÃÖê †−Öã¯ÖÛÃ£ÖŸÖ ¸üÆü−Öê úß ÃÖÓ³ÖÖ×¾ÖŸÖ †¾Ö×¬Ö …
Proposed date of commencement of journey and in case
of family probable duration of absence from Head Quarters.

8. ”ãû™ü™üß úß †¾Ö×¬Ö †Öî¸ü ˆÃ֍úÖ Ã¾Öºþ¯Ö ŸÖÖ¸üßÖ ÃÖ×ÆüŸÖ : ___________________________

(μÖפü ¯Öê¿ÖÖß úß ´ÖÖÓÖ êú¾Ö»Ö ¯Ö׸ü¾ÖÖ¸ü êú ×»Ö‹ úß Ö‡Ô ÆüÖê, ŸÖÖê ‡ÔÃÖ úÖ»Ö´Ö úÖê
³Ö¸ü−Öê úß †Ö¾Ö¿μ֍úŸÖÖ −ÖØÆü Æîü) …
Period and nature of leave with dates :
(This column need not to be filled in, in case of the advance
is claimed for family only.)

9. ׍úÃÖ ÁÖêÖß ´Öë μÖÖ¡ÖÖ úß •ÖÖ−Öß Æîü †Öî¸ü ‡ÔÃÖ ²ÖÖŸÖ úÖ ³Öß ˆ»»ÖêÖ ú¸ëü ׍ú ___________________________
μÖÆü ´Öê»Ö ÖÖ›üß Æîü μÖÖ ¯ÖêÃÖê−•Ö¸ü ÖÖ›üß Æîü …
The class of accommodation by which intends to travel and
Also whether Mail or Passenger.

10. ׯ֔û»Öß ²ÖÖ¸ü μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ »Öê−Öê úß ŸÖÖ¸üßÖ : ___________________________

The date in which the trave concession was last availed of.

11. וÖÃÖ μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ ¯Öê¿ÖÖß êú ×»Ö‹ †Ö¾Öê¤ü−Ö ×¤üμÖÖ ÖμÖÖ Æîü, ˆÃ֍úß ¸üÖ×¿Ö : ___________________________
Amount of advance of T.C. Applied for
 12. μÖפü úÖê‡Ô μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ ¯Öê¿ÖÖß ²ÖúÖμÖÖ ÆüÖê, ŸÖÖê ˆÃ֍úÖ ˆ»»ÖêÖ ú¸ëü … ___________________________
Advance of T.C. outstanding if any.

13. ²μÖÖî¸üÖ (¯Öæ¸üÖ ×¾Ö¾Ö¸üÖ †Öî¸ü ¸üÖ×¿Ö úß Ö¬Ö−ÖÖ ¯ÖÏßÖãŸÖ ú¸ëü †Öî¸ü μÖÆü ²ÖŸÖÖ‹Ó ×ú ___________________________
†Ö¾ÖêפüŸÖ ¯Öê¿ÖÖß úß ¸üÖ×¿Ö úÖ ×ÆüÃÖÖ²Ö îúÃÖê ×−֍úÖ»ÖÖ ÖμÖÖ Æîü … μÖפü ¯Ö׸ü¾ÖÖ¸ü
êú ×»Ö‹ ³Öß ´ÖÖÓÖ úß Ö‡Ô ÆüÖê ŸÖÖê ¯Ö׸ü¾ÖÖ¸ü êú ¯ÖÏŸμÖêú ÃÖ¤üÃμÖ úÖ −ÖÖ´Ö, ˆÃ֍úÖ
ÃÖÓ²ÖÓ¬Ö, †ÖμÖã †Öפü úÖ ²μÖÖî¸üÖ ³Öß ×¤üμÖÖ •ÖÖ‹) …
Details ( full particulars and calculations showing how the
Advance applied for has been arrived at. When claim is
Made for family also, particulars regarding name, relationship
and age of each member of family should be given).

14. †¤üÖμ֐Öß úÖ Ã£ÖÖ−Ö (μÖפü †¤üÖμ֐Öß Ö•ÖÖ−ÖÖ/ˆ¯Ö-Ö•ÖÖ−ÖÖ ÃÖê ׍ú‹ ___________________________
•ÖÖ−Öê êú ×»Ö‹ ¯ÖÏÖ׬֍éúŸÖ úß •ÖÖ−Öß ÆüÖê ŸÖÖê ¾Ö׸üšü »ÖêÖÖ-¯Ö¸ü߁֍ú úÖ
−ÖÖ´Ö ³Öß ×¤üμÖÖ •ÖÖ−ÖÖ “ÖÖ×Æü‹ …
Place of Payment (the name of Sr.Auditor also must be given
When the payments are to be authorised at Treasury / Sub-
Treasury.

15. ‘ÖÖê×ÂÖŸÖ ´Öã»Ö ×−Ö¾ÖÖÃÖ μÖÖ ¾ÖÆü ´Öã»Ö ×−Ö¾ÖÖÃÖ Ã£ÖÖ−Ö •ÖÖê ÃÖê¾ÖÖ ¯ÖãßÖߍúÖ ___________________________
´Öë ˆÛ»»Ö×ÖŸÖ Æîü †Öî¸ü ×−֍ú™üŸÖ´Ö ¸êü»¾Öê Ùêü¿Ö−Ö …
Home Town declared or as in the Service Book and the
nearest Railway Station.

ŸÖÖ¸üßÖ †Ö¾Öê¤üú êú ÆüßÖցָü

Date : Signature of Applicant

16. ¿Ö֏ÖÖ †×¬ÖúÖ¸üß úß ×¿Ö±úÖ¸üß¿Ö … ____________________________________

Recommendations of Branch Officer :

17. ãÖÖ¯Ö−ÖÖ †−Öã³ÖÖÖ úß ×™ü¯¯ÖÖß : ____________________________________

Remarks of Establishment Section :

1. ´Öæ»Ö ×−Ö¾ÖÖÃÖ ÃÖŸμÖÖ×¯ÖŸÖ ×úμÖÖ ÖμÖÖ … ____________________________________

Home Town Verified.
2. ”ãû™ü™üß ´ÖÓ•Öã¸ü úß ÖμÖß … ____________________________________
Leave sanctioned.
3. ____________ºþ¯ÖμÖê úß ¸üÖ×¿Ö †−Öã–ÖêμÖ Æîü †Öî¸ü μÖפü †−Öã¾Öê¤ü−Ö ____________________________________
ÆüÖê ŸÖÖê þÖߍéúŸÖ úß •ÖÖ‹Ó …
An amount of Rs.____________ is admissible
and may be sanctioned if approved.

18. ¸üÖ×¿Ö ×²Ö»Ö ÃÖӏμÖÖ _____________ ŸÖÖ¸üßÖ _________________ ____________________________________

«üÖ¸üÖ †ÖÆü׸üŸÖ úß Ö‡Ô …
Amount drawn vide Bill No.___________ Dated ________

ˆ¯Ö-´ÖÆüÖ»ÖêÖ֍úÖ¸ü ÃÖÆüÖμ֍ú »ÖêÖÖ ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß

Dy. Accountant General Asstt. Audit Officer
ˆ¯Ö ×²Ö»Ö ÃÖÓ / Sub Bill No.___________ Ö.×−Ö.- 25 ŸÖß / TR25-C

¾ÖÂÖÔ ____________ÃÖê ____________ ŸÖú êú ²»Ö֍ú êú ×»Ö‹ ”ãû™ü™üß μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ ×²Ö»Ö
Leave Travel Concession Bill for the Block of the year ______________to______________
×™ü¯¯ÖÖß : μÖÆü ×²Ö»Ö ¤üÖê ¯ÖÏןÖμÖÖêÓ ´Öë ‹ú ÃÖ¤üÖμÖ êú ×»Ö‹ ¤æüÃÖ¸üß úÖμÖÖÔ»ÖμÖ ¯ÖÏ×ŸÖ êú ×»Ö‹ ŸÖîμÖÖ¸ü ׍úμÖÖ •ÖÖ−ÖÖ “ÖÖ×Æü‹ …
Note : This bill should be prepared in duplicate-one for payment and the other as office copy.

³ÖÖÖ - ú (ÃÖ¸üúÖ¸üß ÃÖê¾Öú «üÖ¸üÖ ³Ö¸üÖ •ÖÖ−ÖÖ Æîü)

PART-A (To be filled up by Government Servent)
1. −ÖÖ´Ö / Name _____________________________ 2. ¯Ö¤ü−ÖÖ´Ö / Designation ____________________
3. ¾ÖêŸÖ−Ö / Pay _____________________________ 4. ´ÖãμÖÖ»ÖμÖ / Headquarters ____________________
5. ________________ÃÖê __________________ ŸÖú ´ÖÓ•Öã¸ü úß Ö‡Ô ”ãû™ü™üß úß ¯Öύé×ŸÖ †Öî¸ü †¾Ö׬Ö
Nature and period of leave sanctioned from ________________________to _______________________
6. ãú™ãü´²Ö êú ÃÖ¤üÃμÖÖê úß ×¾Ö׿Ö™üμÖÖÓ, וÖ−֍úß ²ÖÖ¾ÖŸÖ ”ãû™ü™üß μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ úÖ ¤üÖ¾ÖÖ ×úμÖÖ ÖμÖÖ Æîü …
Particulars of members of family in respect of whom the L.T.C. has been claimed
Îú´Ö ÃÖÓ. −ÖÖ´Ö †ÖμÖã ÃÖ¸üúÖ¸üß ÃÖê¾Öú êú ÃÖ´²Ö−¬Ö
S.No. Name Age Relationship with the
Govt. Servant
1.
2.
3.
4.
5.
6.
7. ÃÖ¸üúÖ¸üß ÃÖê¾Öú †Öî¸ü ãú™ãü´²Ö êú ÃÖ¤üÃμÖÖë «üÖ¸üÖ úß Ö‡Ô μÖÖ¡ÖÖ (μÖÖ¡ÖÖ†Öê) êú ²μÖÖê¸êü :
Details of Journey (s) performed by Govt. Servant and the members of his/her family :
¯ÖÏãÖÖ−Ö †ÖÖ´Ö−Ö ¤ãü¸üß ¸üÖ¡Öß úß ¸üߟÖß †Öî¸ü ãÖÖ−Ö, μÖÖ¡Öß ÃÖÓ¤üŸÖ Ø™ü¯¯ÖÖß
S.No. S.No. úß.´Öß.´Öë. ÃÖã×¾Ö¬ÖÖ úÖ ¾ÖÖÔ ×•ÖÃ֍úÖ ³ÖÖ›üÖê μÖÖ¡Öß Remarks
ŸÖÖ¸üßÖ †Öî¸ü ÃÖê ŸÖÖ¸üßÖ ŸÖú Distance ˆ¯ÖμÖÖêÖ ׍úμÖÖ ÖμÖÖ úß ÃÖÓ. ³ÖÖ›üÖ
ÃÖ´ÖμÖ From †Öî¸ü ÃÖ´ÖμÖ To in Kms. Mode of Travel and No. of Fair
Date & Date & class of accomm fares Paid
Time Time odation used

8. ×»Ö‹ Ö‹ †×ÖÏ´Ö úß ¸üú´Ö μÖפü úÖê‡Ô Æî ___________________________ºþ. _________________________________

Amount of advance, if any drawn Rs. __________________________________________________________
9. ˆÃÖ μÖÖ¡ÖÖ/ˆ−Ö μÖÖ¡Ö߆Öê úß ×¾Ö׿Ö™üμÖÖÓ ×•ÖÃ֍êú/וÖ−֍êú ×»Ö‹ ÃÖ¸üúÖ¸üß ÃÖê¾Öú −Öê ˆÃÖ ¾ÖÖÔ ÃÖê וÖÃ֍úÖ ¾ÖÆü Æüú¤üÖ¸ü Æîü, ˆ““ÖŸÖ¸ü ¾ÖÖÔ úß
ãÖÖ−ÖÃÖã×¾Ö¬ÖÖ úÖ ˆ¯ÖμÖÖêÖ ׍úμÖÖ Æîü …
Particulars of Journey (s) for which higher class of accommodation than the one to which the Govt. Servant is
entitled, was used (Sanction Number and date to given)
ãÖÖ−Ö ¾ÖÖÆü−Ö úÖ ¯ÖύúÖ¸ü ¾ÖÆü ¾ÖÖÔ ×•ÖÃ֍úÖ ¾ÖÆü ¾ÖÖÔ ¾ÖßÖãŸÖ: μÖÖ¡ÖÖ ³ÖÖ›üÖê ÃÖÓ¤üŸÖ μÖÖ¡Öß ³ÖÖ›üÖ
Place Mode of Æüú¤üÖ¸ü Æîü μÖÖ¡ÖÖ úß Æîü úß ÃÖӏμÖÖ Fare Paid
ÃÖê ŸÖú Conveyance Class to Class by which No. of ºþ. ¯Öî.
From To which entitled actually Fares Rs. P.
traveled
10. ¸üê»Ö ÃÖê •Öã›êü ãÖÖ−ÖÖë êú ²Öß“Ö, ÃÖ›üú ´Ö֐ÖÔ ÃÖê úß Ö‡Ô μÖÖ¡ÖÖ / μÖÖ¡ÖÖ†Öë êú ²μÖÖî¸êü :
Particulars of Journey (s) performed by road between places connected rail :-

ãÖÖ−ÖÖë êú −ÖÖ´Ö ¸êü»Ö μÖÖ¡Öß ³ÖÖ›üÖ

Name of Places Rail fare
ÃÖê ŸÖú μÖÆü ¾ÖÖÔ ×•ÖÃ֍úÖ Æüú¤üÖ¸ü Æîü ºþ.
From To Class to which entitled Rs.

¯ÖÏ´ÖÖ×ÖŸÖ ×úμÖÖ •ÖÖŸÖÖ Æîü ׍ú / Certified that the

1. ˆ¯Ö¸ü ¤üß Ö‡Ô •ÖÖ−֍úÖ¸üß ´Öê¸êü ÃÖ¾ÖÖìŸÖË´Ö –ÖÖ−Ö †Öî¸ü ×¾ÖÁ¾ÖÖÃÖ êú †−ÖãÃÖÖ¸ü ÃÖŸμÖ Æîü, †Öî¸ü
Information as given above is true to the best of my knowledge and belief and
2. ´Öê¸üÖ ¯ÖןÖ/´Öê¸üÖ ¯ÖŸ−Öß ÃÖ¸üúÖ¸üß ÃÖê¾ÖÖ ´Öê ×−ÖμÖÖê×•ÖŸÖ −ÖÆüß Æîü/´Öê¸üÖ ¯ÖןÖ/´Öê¸üß ¯ÖŸ−Öß ÃÖ¸üúÖ¸üß ÃÖê¾ÖÖ ´Öê ×−ÖμÖÖê×•ÖŸÖ Æîü †Öê¸ü ˆÃÖ−Öê ________¾ÖÂÖÔ êú
²»ÖÖêú êú ¤üÖî¸üÖ−Ö †¯Ö−Öê ×»Ö‹ μÖÖ ãú™ãü´²Ö êú ׍úÃÖß ÃÖ¤üÃμÖ êú ×»Ö‹ ׸üμÖÖμÖŸÖ úÖ ˆ¯ÖμÖÖêÖ −ÖÆüß ×úμÖÖ Æîü …
That my husband/wife is not employed in Government service/that my husband/wife is employed in Government
service and the concession has not been availed of by him/her separately of himself/herself or for any of the
family members for concerned block of ________________years.

ÃÖ¸üúÖ¸üß ÃÖê¾Öú êú ÆüßÖցָü / Signature of Government Servant

ŸÖÖ¸üßÖ / Date
³ÖÖÖ - Ö (×²Ö»Ö †−Öã³Ö֐ִÖë ³Ö¸üÖ •ÖÖ−ÖÖ Æîü)
PART – B (To be filled in the Bill Section)

1. ”ãû™ü™üß μÖÖ¡ÖÖ ´Ö¤ü¤êü ¿Öã¨ü ÆüμÖ¤üÖ¸üß______________________ºþ. ²Ö“Öß Æîü וÖÃ֍êú ²μÖÖî¸êü −Öß“Öê פü‹ Æîü :-
(ú) ¸êü»Ö/¾ÖÖμÖã´ÖÖ−Ö/²ÖÃÖ/Ùüß´Ö¸ü μÖÖ¡ÖÖ ³ÖÖ›üÖ ______________________________________ºþ.
(a) Railways/Air/Bus/Steamer fare Rs.______________________________________
(Ö) ¾ÖÖˆ“Ö¸ü ÃÖÓ. ___________ŸÖÖ¸üßÖ ____________ êú †−ÖãÃÖÖ¸ü ×»Ö‹ Ö‹ †×ÖÏ´Ö úß ¸üú´Ö úÖê ‘Ö™üÖ ¤êü …
(b) Less amount of advance drawn vide Voucher No.____________Date____________Rs.________
¿Öã¨ü ¸üú´Ö / Net Amount ºþ./Rs.

2. ¾μÖμÖ _________________________________´Öë ׾֍ú»¯Ö−ÖßμÖ Æîü …

The expenditure is debatable to

×²Ö»Ö ×»Öׯ֍ú êú †ÖªÖÖ¸ü / Initials of Bill Clerck †Ö¤üÖ−Ö †Öî¸ü ÃÖÓ¾ÖŸÖ¸üú †×¬ÖúÖ¸üß êú ÆüßÖցָü/Signature of D.D.O.
¯ÖÏןÖÆüßÖցÖ׸ŸÖ / Countersigned
×−ÖμÖӡ֍ú †×¬ÖúÖ¸üß êú ÆüßÖցָü / Signature of Controlling Officer
¯ÖÏ´ÖÖ×ÖŸÖ ×úμÖÖ •ÖÖŸÖÖ Æîü ׍ú ÁÖß/ÁÖß´ÖŸÖß/ãú´ÖÖ¸üß _________________________________________ úß ÃÖê¾ÖÖ
¯ÖãÛß֍úÖ ´Öë †Ö¾Ö¿μ֍ú ¯ÖÏ×¾ÖÛ™üμÖÖÑ ú¸ü ¤üß Ö‡Ô Æîü …
Certified that necessary entries have been made in Service Book of Shri/Shrimati/Miss_______________
____________________________________________________________

ÃÖê¾ÖÖ ¯ÖãÛß֍úÖ ´Öë ¯ÖÏ×¾Ö™üμÖÖë úÖ †−Öã¯ÖÏ´ÖÖ×ÖŸÖ ú¸ü−Öê êú ×»Ö‹ ¯ÖÏÖ׬֍éúŸÖ †×¬ÖúÖ¸üß êú ÆüßÖցָü
Signature of the officer authorised to attest entries in the Service Book.
 ÃÖÖ´ÖÖ−μÖ ³Ö×¾ÖÂμÖ×−Ö×¬Ö ÃÖê †ÓŸμÖ †ÖÓ׿֍ú ¯ÖÏŸμÖÖÆüÖ¸ü êú ×»Ö‹ †Ö¾Öê¤ü−Ö úÖ ¯Öϯ֡Ö

1. †Ó¿Ö¤üÖŸÖÖ úÖ −ÖÖ´Ö †Öî¸ü ˆÃ֍úÖ »ÖêÖÖ ÃÖÓ. .......................

2. ¯Ö¤ü .......................

3. ¾ÖêŸÖ−Ö .......................

4. †Ö¾Öê¤ü−Ö êú פü−Ö †Ó¿Ö¤üÖŸÖÖ úß •Ö´ÖÖ ¸üÖ¿Öß úÖ ¿ÖêÂÖ .......................

5. (i) †¯Öê×ÖŸÖ †×ÖÏ´Ö úß ¸üÖ¿Öß .......................

(ii) ‡Ã֍êú ¯ÖÆü»Öê μÖפü úÖê‡Ô †×ÖÏ´Ö ×»ÖμÖÖ ÆüÖê ŸÖÖê ˆÃ֍úß
¸üÖ¿Öß ŸÖ£ÖÖ ˆÃÖê »Öê−Öê úß ×¤ü−ÖÖӍú úÖ ×¾Ö¾Ö¸üÖ ²ÖŸÖÖ‹Ñ … .......................

6. ³ÖéÖŸÖÖ−Ö úß ×ú¿ŸÖë ŸÖ£ÖÖ ²ÖúÖμÖÖ ¿ÖêÂÖ ......................

7. ¯ÖÏμÖÖê•Ö−Ö ×•ÖÃ֍êú ×»Ö‹ †×ÖÏ´Ö úß •Öºþ¸üŸÖ Æîü ......................

8. ŒμÖÖ ×¯Ö”û»ÖÖ †×ÖÏ´Ö ÃÖÖ.³Ö.ÃÖß.‹ÃÖ.×−ÖμÖ´ÖÖë êú

×−ÖμÖ´Ö. 15.(i) (ÃÖß) ´Ö¤ü ÃÖÓ. (1) êú ŸÖÆüŸÖ þÖߍúÖμÖÔ
¸üÖ¿Öß êú 2/3 ÃÖê ú´Ö −ÖÆüß ×»ÖμÖÖ £ÖÖ †Öî¸ü ŒμÖÖ ˆÃ֍êú ÃÖÓ¯ÖæÖÔ
¯Öã−Ö: ³ÖãÖŸÖÖ−Ö úÖê 12 ´Ö×Æü−Öê −ÖÆüà ²ÖßŸÖ “Öãêú Æïü … .....................

9. †Ã£ÖÖμÖß ¯ÖÏŸμÖÖÆüÖ¸ü êú †Ö¾Öê¤ü−Ö úÖ †Öîד֟μÖ ²ÖŸÖÖŸÖê Æãü‹

†Ó¿Ö¤üÖŸÖÖ ¯Ö׸üÛãÖ×ŸÖ úÖ ÃÖÓ¯ÖæÖÔ ²μÖÖê¸üÖ .....................

10. (i) •Ö−´Ö ŸÖÖ¸üßÖ : ...................

(ii) ×−ÖμÖãÛŒŸÖ úß ŸÖÖ¸üßÖ : ...................

(iii) ÃÖê¾ÖÖ ´ÖãŒŸÖ ÆüÖ−Öê úß ŸÖÖ¸üßÖ : ...................

†Ö¾Öê¤üú êú ÆüßÖցָü

úÖÓ»Ö´Ö ÃÖÓ.7 ´Öë ²ÖŸÖÖ‹ Æãü‹ ÃÖÓ³ÖÖ×¾ÖŸÖ Ö“ÖÔ úÖ ²μÖÖî¸üÖ …

 úÖμÖÖÔ»ÖμÖ ¯ÖϬÖÖ−Ö ´ÖÆüÖ»ÖêÖ֍úÖ¸ü
(¾ÖÖם֕μÖ ŸÖ£ÖÖ ¯ÖÏÖÛ¯ŸÖ »ÖêÖÖ ¯Ö׸üÖÖ)
Öã•Ö¸üÖŸÖ, †Æü´Ö¤üÖ²ÖÖ¤ü-380009

¤üÖî¸üÖ/ãÖÖ−ÖÖÓŸÖ¸üÖ ¯Ö¸ü μÖÖ¡ÖÖ ³Ö¢Öê úß ¯Öê¿ÖÖß

(¯Öê¿ÖÖß êú ×»Ö‹ μÖÆü ±úÖ´ÖÔ †Ö¾Öê¤üú «üÖ¸üÖ ³Ö¸üÖ •ÖÖ‹)

1. †Ö¾Öê¤üú úÖ −ÖÖ´Ö †Öî¸ü ¯Ö¤ü−ÖÖ´Ö :

2. ¯ÖÏÖμÖÖê•ÖŸÖ וÖÃ֍êú ×»Ö‹ ¯Öê¿ÖÖß úß †Ö¾Ö¿μ֍úŸÖÖ Æîü :
3. ¯Öê¿ÖÖß úß ¸üÖ׿Ö, וÖÃ֍êú ×»Ö‹ †Ö¾Öê¤ü−Ö ×úμÖÖ ÖμÖÖ Æîü
ÃÖÓ³ÖÖ×¾ÖŸÖ Ö“ÖÔ úÖ ²μÖÖî¸üÖ ¤êü :
4. μÖפü úÖê‡Ô ׯ֔û»Öß ²ÖúÖμÖÖ ¯Öê¿ÖÖß ÆüÖê, ŸÖÖê ˆÃ֍úÖ ˆ»»ÖêÖ ú¸ëü †Öî¸ü μÖÆü
²ÖŸÖÖ‹ ׍ú ŒμÖÖ ˆÃ֍úÖ »ÖêÖÖ ¯ÖÏßÖãŸÖ ú¸ü פüμÖÖ Æîü ? μÖפü ׍úμÖÖ ÖμÖÖ Æîü ŸÖÖê
ú²Ö ?
5. μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ ¯Öê¿ÖÖß :
(ú) ãÖÖ−Ö, •ÖÆüÖÑ úß μÖÖ¡ÖÖ úß •ÖÖ−ÖÖ Æîü :
(Ö) ´ÖãμÖÖ»ÖμÖ êú ãÖÖ−Ö ÃÖê ˆÃ֍úß ¤æü¸üß :
(Ö) ¯ÖϤüÖ−Ö úß Ö‡ ”ãû™ü™üß úß †¾Ö×¬Ö †Öî¸ü ˆÃ֍úÖ Ã¾Öºþ¯Ö :
6. ˆÃÖ Ã£ÖÖ−Ö úÖ ¯ÖŸÖÖ, •ÖÆüÖÓ ¸üÖ×¿Ö ³Öê•Öß •ÖÖ−Öß Æîü, †Öî¸ü ¾ÖÆü ²ÖŸÖÖ‹Ó ×ú ŒμÖÖ
‡ÃÖê †Ö¾Öê¤üú êú †¯Ö−Öê Ö“ÖÔ ¯Ö¸ü ²Öïú ›ÒüÖ¯™ü ÃÖê ³Öê•ÖÖ •ÖÖ‹ μÖÖ ´Ö−Ö߆Öê›Ôü¸ü
«üÖ¸üÖ ³Öê•ÖÖ •ÖÖ‹ :

†Ö¾Öê¤üú êú ŸÖÖ¸üßÖ ÃÖ×ÆüŸÖ ÆüßÖցָü

 úÖμÖÖÔ»ÖμÖ ¯ÖϬÖÖ−Ö ´ÖÆüÖ»ÖêÖ֍úÖ¸ü (¾ÖÖם֕μÖ ‹¾ÖÓ ¯ÖÏÖÛ¯ŸÖ »ÖêÖÖ¯Ö¸ü߁ÖÖ),Öã•Ö¸üÖŸÖ
†Öò×›ü™ü ³Ö¾Ö−Ö, −Ö¾Ö¸ÓüÖ¯Öã¸üÖ, †Æü´Ö¤üÖ²ÖÖ¤ü - 380 009
OFFICE OF THE PR. ACCOUNTANT GENERAL
(Commercial and Receipt Audit), Gujarat, Ahmedabad

ÃÖÓ.†Ö¸.‹.-2/ÃÖß.‡Ô.†Ö¸ü.‹./×−Ö.׸ü/ פü−ÖÖӍú :

ÃÖê¾ÖÖ ´Öë,
ÃÖÆüÖμ֍ú †ÖμÖãŒŸÖ êú−¦üßμÖ ˆŸ¯ÖÖ¤ü ¿Ö㻍ú
×›ü×¾Ö•Ö−Ö

×¾ÖÂÖμÖ : ôÖé×ŸÖ¯Ö¡Ö ‹»Ö.‹.†Ö¸ü .........................¯Öî¸Ö ÃÖÓ ..................)

‡ÃÖ úÖμÖÖÔ»ÖμÖ êú ¯Ö¡Ö Îú´ÖÖӍú †Ö¸ü.-2/×−Ö.׸ü./ÃÖß. ‡Ô. †Ö¸ü. ‹./ ................................
פü−ÖÖӍú .............
êú ÃÖÖ£Ö ÃÖӻ֐−Ö ¸ëü−•Ö..............×›ü×¾Ö•Ö−Ö................úß Ã£ÖÖ−ÖßμÖ »ÖêÖÖ¯Ö¸ü߁ÖÖ ×¸ü¯ÖÖê™Ôü êú ÃÖÓ¤ü³ÖÔ
´Öë μÖÆü ¤ü¿ÖÖÔμÖÖ
•ÖÖŸÖÖ Æîü ׍ú ²ÖúÖμÖÖ ¯Öî¸üÖ ÃÖÓ................. êú •Ö¾ÖÖ²Ö †³Öß ŸÖú ¯ÖÏÖ¯ŸÖ −ÖÆüß Æãü‹ Æïü …
éú¯ÖÖ ú¸üêú ²ÖúÖμÖÖ ¯Öî¸üÖ êú ˆ¢Ö¸ü ¿Öß‘ÖÐ ‡ÃÖ úÖμÖÖÔ»ÖμÖ úÖê ³Öê•Ö−Öê úÖ ¯ÖϲÖÓ¬Ö ú¸ëü…

¯ÖÏÖÛ¯ŸÖ »ÖêÖÖ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß (†Ö¸ü.‹.-2)

¯ÖÏןÖ×»Ö×¯Ö ¯ÖÏê×ÂÖŸÖ :
1. ˆ¯Ö †ÖμÖãŒŸÖ êúÛ−¤üμÖ ˆŸ¯ÖÖ¤ü ¿Ö㻍ú (»Öê.¯Ö.)
†Ö¤Ôü¿Ö¬ÖÖ´Ö ³Ö¾Ö−Ö, ¾ÖÖ¯Öß ¯ÖÖê×»ÖÃÖ “ÖÖî׍ú êú
ÃÖÖ´Ö−Öê, ¾ÖÖ¯Öß - ¤ü´Ö−Ö ¸üÖê›ü ¾ÖÖ¯Öß

¯ÖÏÖÛ¯ŸÖ »ÖêÖÖ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß (†Ö¸ü.‹.-2)

¤ü»Ö úÖ −ÖÖ´Ö :
(Name of the party)

¸ëü•Ö (Öê¡Ö) úÖ −ÖÖ´Ö †Öî¸ü ¯ÖŸÖÖ :

(Name & address of the Range)

×›ü×¾Ö•Ö−Ö úÖ −ÖÖ´Ö †Öî¸ü ¯ÖŸÖÖ :

(Name & address of the Division)

ú×´Ö¿−Ö¸êü™ü úÖ −ÖÖ´Ö †Öî¸ü ¯ÖŸÖÖ :

(Name & address of the Comm.)

μÖã×−Ö™ü úÖ −ÖÖ´Ö †Öî¸ü ¯ÖŸÖÖ :

(Name & address of the Unit)

†ÓêúÖ êú ×»Ö‹ ×»ÖμÖÖ ÖμÖÖ ¾ÖÂÖÔ :

(Period covered in Audit)

†ÓêúÖ úÖ ×¤ü−ÖÖӍú :

(Dates of Audit)

ÃÖê¾ÖÖ ú¸ü ‹»Ö. ‹. †Ö¸ü. : ÆüÖò/Yes −ÖÖ/No

Service tax LAR
 ”ãû™ü™üß úß ¯Ö“Öß úÖ ±úÖ´ÖÔ
Form of Application For Leave
(†−Öã¯Öã¸üú ×−ÖμÖ´Ö 216 ¤êü׏ÖμÖê / See supplementary Rule216)
×™ü¯¯ÖÖß - ´Ö¤ü ÃÖÓ. 1 ÃÖê 12 ¯ÖÏŸμÖêú ¯ÖÏÖ£Öá úÖê ³Ö¸ü−Öß “ÖÖ×Æü‹ “ÖÖÆêü ¾ÖÆü ¸üÖ•ÖμÖ×¡ÖŸÖ ÆüÖê μÖÖ ²Ö¸üÖ•Ö¯Ö×¡ÖŸÖ …
Note :- Item 1 to 12 must be filled in by all applecants whether gazetted or non-gazetted.

1. ¯ÖÏÖ£Öá úÖ −ÖÖ´Ö

1. Name of applicant
2. »Ö֐Öã ÆüÖ−ê Öê ¾ÖÖ»Öß ”ãû™ü™üß ×−ÖμÖ´ÖÖ¾Ö»Öß
2. Leave Rules applicable
3. ¯Ö¤ü
3. Post held
4. ×¾Ö³ÖÖÖ úÖμÖÖÔ»ÖμÖ †Öî¸ü †−Öã³Ö֐Ö
4. Department Office and Section
5. ¾ÖêŸÖ−Ö †Öî¸ü ¾ÖêŸÖ−Ö ¾Ö鬬Öß úß ŸÖÖ¸üߏÖ
5. Pay and Date of Increment
6. ¾ÖŸÖÔ´ÖÖ−Ö ¯Ö¤ü ¯Ö¸ü ×´Ö»Ö−Öê ¾ÖÖ»ÖÖ ´ÖúÖ−Ö ×ú¸üÖμÖÖ ³Ö¢ÖÖ ÃÖ¾ÖÖ¸üß ³Ö¢ÖÖ μÖÖ †−μÖ ¯ÖÏן֍úÖ¸ü ³Ö¢Öê
6. House rent allowance, conveyance, allowance or other
Compensatory allowance drawn in the present post.
7. ´ÖÖӐÖß Ö‡Ô ”ãû™ü™üß úß ×úÃ´Ö †¾Ö×¬Ö †Öî¸ü ˆÃ֍êú ¿Öãºþ ÆüÖ−ê Öê úß ŸÖÖ¸üߏÖ
7. Nature and period of leave applied for and date from which required.
8. ¸ü×¾Ö¾ÖÖ¸ü †Öî¸ü ”ãû™ü™üß êú פü−Ö, μÖפü úÖê‡Ô ÆüÖê, וÖ−Æêü ”ãû™ü™üß êú ¯ÖÆü»Öê ²ÖÖ¤ü ´Öë •ÖÖê›ü−ÖÖ “ÖÖÆüŸÖÖ Æîü …
8. Sundays and Holidays if any, proposed to be prefixed / suffixed to leave.
9. ”ãû™ü™üß úÖ úÖ¸üÖ
9. Ground on which leave, is applied for
10. ׯ֔û»Öß ”ãû™ü™üß ÃÖê »ÖÖî™ü−Öê úß ŸÖÖ¸üßÖ ˆÃÖ ”ãû™ü™üß úß ×úÃ´Ö ŸÖ£ÖÖ †¾Ö׬Ö
10. Date of return from last leave and the nature and period of that leave.
11. ”ãû™ü™üß úÖ ¯ÖŸÖÖ
11. Leave address
12. ´Öê¸üÖ ×²Ö“ÖÖ¸ü †ÖÖÖ´Öß ”ãû™ü™üß ´Öë_____________êú
Ö›ü ¾ÖÂÖÖì êú ×»ÖμÖê ”ãû™ü™üß μÖÖ¡ÖÖ úß ×¸ü¾ÖÖ¯Ö¡Ö »Öê−Öê úÖ Æîü/−ÖÆüß Æîü
12. I Propose/do not propose to avail myself of Leave
Travel Concession for the block years__________during the ensuing leave.
13. (ú) ´Öî ¾Ö“Ö−Ö ¤êüŸÖÖ Æãü ׍ú †ÖîÃÖŸÖ ¾ÖêŸÖ−Ö ”ãû™ü™üß / ¯Ö×−Ö¾Ö×ŸÖŸÖ ”ãû™ü™üß úÖ †¾Ö×¬Ö ´Öë ×»ÖμÖê ÖμÖê ”ãû™ü™üß ¾ÖêŸÖ−Ö †Öî¸ü †Ö¬Öê †ÖîÃÖŸÖ ¾ÖêŸÖ−Ö/†Ö¬Öê ¾ÖêŸÖ−Ö úß
”ãû™ü™üß ×´Ö»Ö−Öê ¾ÖÖ»Öê ¾ÖêŸÖ−Ö êú †−ŸÖ¸ü úß ˆÃÖ ¸üú´Ö úÖê ¾ÖÖ¯ÖÃÖ ú¸ü ¤æÓüÖÖ •ÖÖê ”ãû™ü™üß úß ÃÖ´ÖÖÛ¯ŸÖ ¯Ö¸ü †£Ö¾ÖÖ ˆÃ֍êú ¤üÖî¸üÖ−Ö ´Öê¸êü ÃÖê¾ÖÖ ×−Ö¾ÖéŸÖ
ÆüÖê−Öê úß ÛãÖ×ŸÖ ´Öë Öæ»Ö ×−ÖμÖ´Ö 81 (‘Ö) (ii) ÃÖÓ¿ÖÖê×¬ÖŸÖ ”ãû™ü™üß ×−ÖμÖ´ÖÖ¾Ö»Öß 1933 êú ×−ÖμÖ´Ö 11 (iii) êú »Ö֐Öæ −Ö ÆüÖê−Öê ¯Ö¸ü †−Öã´ÖŸμÖ −Ö ÆüÖê−Öß …
13. (a) I undertake to refund the difference between the leave salary drawn during leave on average pay/commuted leave and
that admissible during leave on half average half/pay leave which would not have been admissible had the provision of F
R 81 (b) (ii) rule 11(c) (iii) of the Revised Leave Rules 1993 not been applied in the event of my retirement from service
at the end or during the currency of the leave.
13. (Ö) ´Öî ¾Ö“Ö−Ö ¤êüŸÖÖ ÆãÓü ׍ú ´Öê¸êü þÖê“”ûÖ ÃÖê ×−Ö¾ÖéŸÖ ÆüÖ−ê Öê μÖÖ ÃÖê¾ÖÖ ÃÖê ŸμÖÖÖ¯Ö¡Ö ¤êü−Öê ŸÖú ´Öî ú´Ö ÃÖê ú´Ö †Ö¬Öê ¾ÖêŸÖ−Ö úß ˆŸÖ−Öß ”ãû™ü™üß †Ù•ÖŸÖ −Ö ú¸ü
Ã֍êú ו֟Ö−Öß †×ÖÏ´Ö ”ãû™ü™üß ´Öî−Öê »Öß Æîü ŸÖÖê ´Öî †×ÖÏ´Ö ”ãû™ü™üß êú ¤üÖî¸üÖ−Ö •ÖÖê ´Öæ»Ö ×−ÖμÖ´Ö 85 (Ö) ÃÖÓ¿ÖÖê×¬ÖŸÖ ”ãû™ü™üß ×−ÖμÖ´ÖÖ¾Ö»Öß 1933 êú ×−ÖμÖ´Ö
11(‘Ö) êú »Ö֐Öã ¾Ö ×úμÖê •ÖÖ−Öê ¯Ö¸ü ´Öã—Öê −Ö ×´Ö»Ö ¯ÖÖŸÖß, ×´Ö»Öê ”ãû™ü™üß êú ¾ÖêŸÖ−Ö úÖê ¾ÖÖ¯ÖÃÖ ú¸ü ¤æÓüÖÖ …
13. (b) I undertake to refund the leave salary drawn leave not due I’which would not have been admissible had F.R. 81 (c) Rules
11 (d) of the Revised Rules 1933 not been applied in the event of my voluntary retirement of resignation from service of
any time, Until I earn half pay leave not less than the amount of leave not due availed of by me.

ŸÖÖ¸üßÖ ÆüßÖցָü
Date____________ Signature of Applicant_______________
14. ×−ÖμÖÓ¡ÖÖ †×¬ÖúÖ¸üß úß ×™ü¯¯ÖÖß †Öî¸ü/μÖÖ ×ÃÖ±úÖ׸ü¿Ö
14. Remark and/or recommendation of
the controlling Officer

ŸÖÖ¸üßÖ ÆüßÖցָü
Date ________ Signature __________________

¯Ö¤ü−ÖÖ´Ö
Designation ________________

”ãû™ü™üß úß †−Öã´ÖŸμÖŸÖÖ êú ²ÖÖ¸êü ´Öë ¯ÖÏ´ÖÖÖ ¯Ö¡Ö

Certificate Regarding Admissibility of Leave
(¸üÖ•Ö¯Ö×¡ÖŸÖ †×¬ÖúÖ¸ü߆Öë êú ÃÖ´²Ö−¬Ö ´Öë ´ÖÆüÖ»ÖêÖ֍úÖ¸ü «üÖ¸üÖ)
(By Accountant General in the case of gazzetted officers)

15. ¯ÖÏ´ÖÖ×ÖŸÖ ×úμÖÖ •ÖÖŸÖÖ Æîü ׍ú___________________________________ÃÖê__________________________

ŸÖú _____________________פü−Ö êú ×»ÖμÖê__________________×−ÖμÖ´ÖÖ¾Ö»Öß êú ×−ÖμÖ´Ö________________
êú †Ö׬Ö−Ö________________†−Öã´ÖŸμÖ Æîü …
16. Certified that_______________________________________________________________________
(Nature of leave)
for ________________________from_________________________to_________________________
(period)
is, admissible under rule_________________________of the Rules____________________________

ŸÖÖ¸üßÖ ÆüßÖցָü
Date_________________ Signature________________

¯Ö¤ü−ÖÖ´Ö
Designation______________

16. Ûþ֍éúŸÖß ¯ÖÖ−Öê¾ÖÖ»Öê †×¬ÖúÖ¸üß êú †Ö¤êü¿Ö :-

16. Order of the sanctioning authority :-

ŸÖÖ¸üßÖ ÆüßÖցָü
Date________________ Signature_______________

¯Ö¤ü−ÖÖ´Ö
Designation_____________
* μÖפü ¯ÖÏÖ£Öá úÖê úÖê‡Ô ¯ÖÏן֍úÖ¸ü ³ÖŸŸÖÖ ×´Ö»ÖŸÖÖ ÆüÖê ŸÖÖê ´ÖÓ•Öã¸üß ¤êü−Öê ¾ÖÖ»Öê †×¬ÖúÖ¸üß úÖê μÖÆü ׻֏Ö−ÖÖ “ÖÖ×Æü‹ ׍ú
”ãû™ü™üß ¯Öæ¸üß ÆüÖ−ê Öê ¯Ö¸ü ¯ÖÏÖ£Öá ˆÃÖ ¯Ö¸ü μÖÖ ×úÃÖß ‹ÃÖê ¯Ö¤ü ¯Ö¸ü »ÖÖî™ü−Öê úß †Ö¿ÖÖ Æîü μÖÖ −ÖÆüßÓ •ÖÆüÖÓ ‡ÃÖß ¯ÖύúÖ¸ü úÖ ³Ö¢ÖÖ ×´Ö»ÖŸÖÖ Æîü …
* If the applicant is drawing any Compensatory allowance, the sanctioning authority should state
whether on the expiry of leave he is likely to the same post or to another post carrying a similar allowance.
(²Ö) ŒμÖÖ †Ö¾Öê¤üú −Öê †¯Ö−Öê «üÖ¸üÖ μÖÖ †¯Ö−Öê ¯Ö׸ü¾ÖÖ¸ü «üÖ¸üÖ úß •ÖÖ−Öê¾ÖÖ»Öß μÖÖ¡ÖÖ úß ŸÖÖ¸üßÖ úÖê ´ÖÆüÖ»ÖêÖ֍úÖ¸ü úÖ úÖμÖÖÔ»ÖμÖ
‹ú ¾ÖÂÖÔ úß »ÖÖÖŸÖÖ¸ü ÃÖê¾ÖÖ ¯Öæ¸üß ú¸ü »Öß Æîü ?
(d) Whether the applicant has completed one year’s continuous
OFFICE OF THE ACCOUNTANT GENERAL
service on the date of journey to be performed by him or his (C & R.A.) GUJARAT, AHMEDABAD.
family?
(›ü) ŒμÖÖ ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß ³ÖÖ¸üŸÖ ÃÖ¸üúÖ¸ü, ÖéÆü ´ÖÓ¡ÖÖ»ÖμÖ êú ŸÖÖ¸üßÖ 1-10-56 êú †Ö¤êü¿Ö ¤üÖî¸Ö/ãÖÖ−ÖÖÓŸÖ¸üÖ ¯Ö¸ü μÖÖ¡ÖÖ ³Ö¢Öê úß ¯Öê¿ÖÖß
ÃÖӏμÖÖ 43/1/55 ãÖÖ¯Ö−ÖÖ-ú-³ÖÖÖ êú †−ŸÖÖÔŸÖ ×¸üμÖÖμÖŸÖ êú ×»Ö‹ ¯ÖÖ¡Ö Æîü ? ADVANCE OF T.A.ON TOUR/TRANSFER
(e) Whether the Government Servant is eligible for the concession
under G.I.M.H.A.No.43/1/55/Estts.A-pt, dated 1-10-56 ?
(“Ö) ŒμÖÖ ¯Öê¿ÖÖß †Ö−Öê †Öî¸ü •ÖÖ−Öê ¤üÖê−ÖÖë Æüß μÖÖ¡ÖÖ†Öë êú ÃÖÓ²ÖÓ¬Ö ´Öë Æîü ? ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß «üÖ¸üÖ (¯Öê¿ÖÖß êú ×»Ö‹ μÖÆü ±úÖ´ÖÔ †Ö¾Öê¤üú «üÖ¸üÖ ³Ö¸üÖ •ÖÖ‹)
»Öß Ö‡Ô ”ãû™ü™üß úß †¾ÖÖ×¬Ö μÖÖ ¯Ö׸ü¾ÖÖ¸ü êú ÃÖ¤üÃμÖÖêÓ úß †−Öã¯ÖÛãÖ×ŸÖ úß †¾Ö×¬Ö 3 ´ÖÖÃÖ μÖÖ (To be filled in by the applicant for advance)
90 פü−Ö ÃÖê ¤ü׬֍ú ŸÖÖê −ÖÆüß Æîü ? •ÖÖÓ“Ö úß Ö‡Ô †Öî¸ü šüߍú ¯ÖÖμÖÖ ÖμÖÖ
..................................ºþ. êú ×»Ö‹ †Ö¾ÖêפüŸÖ ¯Öê¿ÖÖß êú ãÖÖ−Ö ¯Ö¸ü
..................ºþ. úß ¯Öê¿ÖÖß … †−Öã–ÖêμÖ Æîü †Öî¸ü ‡Ã֍úß ´ÖÓ•Öã¸üß ¤üß •ÖÖ‹ …
(f) Is the advance is in respect of both the forward and return 1. †Ö¾Öê¤üú úÖ −ÖÖ´Ö †Öî¸ü ¯Ö¤ü−ÖÖ´Ö :
journeys? 1. Name of applicant and designation :
Whether the period of leave taken by the Government Servant or
the period anticipated abserce of the members of the family does
not exceed 3 months or 90 days ?
Checked and found in order, An advance of Rs. .......................... 2. ¯ÖÏμÖÖê•ÖŸÖ וÖÃ֍êú ×»Ö‹ ¯Öê¿ÖÖß úß †Ö¾Ö¿μ֍úŸÖÖ Æîü : ¤üÖî¸üÖ/ãÖÖ−ÖÖÓŸÖ¸üÖ
As agalrse Rs. ...................applied for is admissible and may be 2. Purpose for which advance is required : Tour/Transfer
sanctioned.

3. ¯Öê¿ÖÖß úß ¸üÖ¿Öß, וÖÃ֍êú ×»Ö‹ †Ö¾Öê¤ü−Ö ×úμÖÖ ÖμÖÖ Æîü

†−Öã³ÖÖÖ †×¬ÖúÖ¸üß ÃÖÓ³ÖÖ×¾ÖŸÖ Ö“ÖԍúÖ ²μÖÖî¸üÖ ¤ëü :
Section Officer 3. Amount of advance applied for
Give details of probable expenses :

ÃÖÆüÖμ֍ú »ÖêÖÖ-¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß »ÖêÖÖ ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß

Asstt. Audit Officer Audit Officer 4. μÖפü úÖê‡Ô ׯ֔û»Öß ²ÖúÖμÖÖ ¯Öê¿ÖÖß ÆüÖê, ŸÖÖê ˆÃ֍úÖ ˆ»»ÖêÖ ú¸ü †Öî¸ü μÖÆü ²ÖŸÖÖ‹
׍ú ŒμÖÖ ˆÃ֍úÖ »ÖêÖÖ ¯ÖÏßÖãŸÖ ú¸ü פüμÖÖ Æîü, μÖפü ׍úμÖÖ Æîü ŸÖÖê ú²Ö !
4. Last advance outstanding, If any, and whether account for
(¾Ö׸üšü-ˆ¯Ö-´ÖÆüÖ»ÖêÖ֍úÖ¸ü) it has been rendered, if so, when?
(Sr. Dy. Accountant General)

(×™ü¯¯ÖÖß : •ÖÖê ´Öã¤ü¤êü »Ö֐Öã −Ö ÆüÖê ˆ−Æëü úÖ™ü ¤ëü …)

(Note : Strike out the items not applicable)
5. μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ ¯Öê¿ÖÖß :
5. Travel concession Advance : ( úÖμÖÖÔ»ÖμÖ êú ¯ÖÏμÖÖêÖ êú ×»Ö‹ )
(FOR USE IN THE OFFICE)
1. †Ö¾Öê¤üú †Ã£ÖÖ‡Ô Æïü μÖÖ Ã£ÖÖμÖß ?
(ú) ãÖÖ−Ö, •ÖÆüÖÑ úß μÖÖ¡ÖÖ úß •ÖÖ−Öß Æîü
(a) Place to which Journey is to be made 1. Whether applicant is temporary or permanent ?

2. μÖפü †Ã£ÖÖμÖß Æîü, ŸÖÖê ÃÖ´ÖÖ−Ö †ÖêÆü¤êü êú μÖÖ ˆÃ֍êú ˆÑ“Öê †ÖêÆü¤êü êú ׍úÃÖß Ã£ÖÖμÖß ÃÖ¸üúÖ¸üß ú´ÖÔ“ÖÖ¸üß
úÖ ¯ÖÏןֲÖÓ¬Ö ¯Ö¡Ö ¯ÖÏßÖãŸÖ ׍úμÖÖ ÖμÖÖ Æîü ?
(Ö) ´ÖãμÖÖ»ÖμÖ êú ãÖÖ−Ö ÃÖê ˆÃ֍úß ¤æü¸üß : 2. If temporary, whether surety bond has been furnished from a
(b) Les distance from the Head Quarter Station permanent Government Servant of comparable status of higher status
?

(Ö) ¯ÖϤüÖ−Ö úß Ö‡Ô ”ãû™ü™üß úß †¾Ö×¬Ö †Öî¸ü ˆÃ֍úÖ Ã¾Öºþ¯Ö : 3. ¯ÖÏ׬֍úÖ¸üß ×•ÖÃ֍êú †−ŸÖÖÔŸÖ ¯Öê¿ÖÖß †−Öã–ÖêμÖ Æîü …
(c) Period and nature of leave granted : 3. Authority under which advance is admissible.

4. ׯ֔û»Öß ²ÖúÖμÖÖ ¯Öê¿ÖÖß, μÖפü úÖê‡Ô ÆüÖê †Öî¸ü ŒμÖÖ ˆÃ֍úÖ »ÖêÖÖ ¯ÖÏßÖãŸÖ ú¸ü פüμÖÖ ÖμÖÖ Æîü, μÖפü
6. ˆÃÖ Ã£ÖÖ−Ö úÖ ¯ÖŸÖÖ, •ÖÆüÖÓ ¸üÖ×¿Ö ³Öê•Öß •ÖÖ−Öß Æîü, †Öî¸ü ¾ÖÆü ²ÖŸÖÖ‹ ׍ú ŒμÖÖ ‡ÃÖê †Ö¾Öê¤üú êú ׍úμÖÖ ÖμÖÖ Æîü, •ÖÖê ú²Ö ¯ÖÖßÖãŸÖ ׍úμÖÖ ÖμÖÖ Æîü ?
†¯Ö−Öê Ö“ÖÔ ¯Ö¸ü ²Öïú ›ÒüÖ±ú™ü ÃÖê ³Öê•ÖÖ •ÖÖ‹ μÖÖ ´Ö−Ö߆֛Ôü¸ü «üÖ¸üÖ ³Öê•ÖÖ •ÖÖ‹ : 4. Last advance outstanding, if any and whether account for it has been
6. Address to which the amount is to be sent and whether it should be rendered if so, when ?
sent by Bank Draft of M.O. at his own expenses.
5. μÖÖ¡ÖÖ ×¸üμÖÖμÖŸÖ ¯Öê¿ÖÖß :
5. Travel Concession Advance :
(ú) ‘ÖÖê×ÂÖŸÖ ´Öæ»Ö ×−Ö¾ÖÖÃÖ Ã£ÖÖ−Ö úÖ −ÖÖ´Ö †Öî¸ü ú´Ö ¤ãü¸üß ¾ÖÖ»Öê ´Ö֐ÖÔ ÃÖê ˆÃ֍úÖ −Öו֍úŸÖ´Ö
Ùêü¿Ö−Ö
(a) Name of the declared Home Town Place and nearest station to it
by the shortest route.
(Ö) וÖÃÖ Ã£ÖÖ−Ö μÖÖ¡ÖÖ úß •ÖÖ−Öß Æîü, úμÖÖ ¾ÖÆü ãÖÖ−Ö ´ÖãμÖÖ»ÖμÖ êú ãÖÖ−Ö ÃÖê 250 ×´Ö»Ö ÃÖê
†Ö¾Öê¤üú êú ŸÖÖ¸üßÖ ÃÖ×ÆŸÖ ÆüßÖցָü †−Öã³ÖÖÖ †×¬ÖúÖ¸üß/ÃÖÆüÖμ֍ú »ÖêÖÖ ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß †×¬Öú ¤ãü¸üß ¯Ö¸ü Æîü ?
Dated Signature of the Applicant ¯ÖÖ™üá êú ¯ÖϳÖÖ¸üß ¸üÖ•Ö¯Ö×¡ÖŸÖ †×¬ÖúÖ¸üß êú ÆüßÖցָü (b) Whether the place to which journey is to be made is beyond a
Signature of the S.O./A.A.O./G.O. distance of 250 miles from the Head Quarter’s Station ?
In charge of Party (Ö) ŒμÖÖ ¯ÖϤüÖ−Ö úß Ö‡Ô ”ãû™ü™üß (†ÖúÛô֍ú ”ãû™ü™üß ÃÖê ׳֮Ö) 15 פü−Ö ÃÖê ú´Ö Æîü ?
(c) Whether leave (Other than Casual Leave) granted is not less
than 15 days ?
 פü−ÖÖӍú : . .200
ÃÖê¾ÖÖ ´Öë

†ŸÖß †Ö¾Ö¿μ֍ú ‘Ö¸êü»Ö㠍úÖμÖÔ ÆüÖê−Öê úß ¾Ö•ÖÆü ÃÖê ´Öî פü. - -200 úÖê
úÖμÖÖÔ»ÖμÖ ´ÖêÓ ˆ¯ÖÛÃ£ÖŸÖ ¸üÆü−Öê ´Öë †ÃÖ´Ö£ÖÔ £ÖÖ… †ŸÖ: ÁÖß´ÖÖ−Ö ÃÖê †−Öã¸üÖê¬Ö Æîü úß ¾ÖÆü
´Öã—Öê ‹ú פü−Ö úß †ÖúÃÖ´Öߍú ”ãû™ü™üß (CL) ¯ÖϤüÖ−Ö ú¸êü …

¬Ö−μÖ¾ÖÖ¤ü …

³Ö¾Ö¤üßμÖ
 FORM-IV

MEDICAL CERTIFICATE FOR LEAVE FOR EXTENSION OF LEAVE OR

COMMUTATION OF LEAVE

Signature of Government Servant : ____________________________

I, ______________________________________ after careful personal examination of the

case hereby certify that Kum./Smt./ Shri____________________________________ is suffering
from ________________ and I consider that a period of absence from duty of
_____________________ with effect from ____________________ is absolutely necessary for the
restoration of his/her health.

Authorised Medical Attendant

____________________________
Hospital/Dispensary
Registered Medical Practitioner

(Registration No.______________)

Date : _________________

FORM-V

Signature of the Government Servant ___________________________

We, the members of Medical Board

I _________________________________ Civil Surgeon/Staff Surgeon/ Authorised Medical
Attendant/Registered Medical Practitioner of _______________________ do hereby certify that We/I
have carefully examined Shri/Smt./Kum. _____________________________ whose signature is
given above and find that he/she recovered from his/her illness and is now fit to resume duties in
Government Service. We/I also certify that before arriving at this decision, We/I have examined the
original medical certificate(s) and statement(s) of the case (or certified copies thereof) on which leave
was granted or extended and have taken these into consideration in arriving at our/my decision.

Members of the Medical Board

(1) ________________________
(2) ________________________
(3) ________________________

Civil Surgeon/Staff Surgeon

Authorised Medical Attendant
Registered Medical Practitioner

Date : ________________

NOTE : The original certificate(s) and statement(s) of the case on which the leave was originally
granted or extended shall be produced before the authority required to issue the above
certificate. For this purpose, the original certificate(s) and statement(s) of the case should be
prepared in duplicate, one copy being retained by the Government Servant concerned.
 úÖμÖÖÔ»ÖμÖ ¯ÖϬÖÖ−Ö ´ÖÆüÖ»ÖêÖ֍úÖ¸ü(¾ÖÖם֕μÖ ‹¾ÖÓ ¯ÖÏÖÛ¯ŸÖ »ÖêÖÖ ¯Ö׸üÖÖ) Öã•Ö¸üÖŸÖ, †Æü´Ö¤üÖ²ÖÖ¤ü
ÃÖê¾ÖÖ ´Öë, פü−ÖÖӍú :
»ÖêÖÖ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß
¯ÖÏ¿ÖÖÃÖ−Ö †−Öã³ÖÖÖ …

´ÖÆüÖê¤üμÖ,

´ÖîÓ †Ö•Ö פü−ÖÖӍú....................¯Öæ¾ÖÖÔÆü−Ö/†¯Ö¸üÖÆü−Ö †¯Ö−Öê ±ú•ÖÔ ¯Ö¸ü ˆ¯ÖÛÃ£ÖŸÖ ÆüÖê−Öê úß ÃÖæ“Ö−ÖÖ ¤êüŸÖÖ/¤êüŸÖß ÆãÑü …
´Öê¸üß †−Öã¯ÖÛãÖ×ŸÖ ×¤ü−ÖÖӍú.....................................................ÃÖê .........................................וÖÃÖê
×ü¤ü−ÖÖӍú........................................êú ˆ¯ÖÃ֐ÖÔ ‹¾ÖÓ......................................†ŸÖÃ֐ÖÔ êú ÃÖÖ£Ö ×−ÖμÖ×´ÖŸÖ
ú¸ü−Öê úß †−Öã´Ö×ŸÖ ¤üß •ÖÖμÖ …
þÖã֟ÖÖ ¯ÖÏ´ÖÖÖ ¯Ö¡Ö ÃÖӻ֐−Ö Æîü …
³Ö¾Ö¤üßμÖ...................
ÆüßÖցָü..................
−ÖÖ´Ö.......................
¯Ö¤ü−ÖÖ´Ö...................

ÁÖß/ÁÖß´ÖŸÖß/ãú´ÖÖ¸üß.................................................êú †¾ÖúÖ¿Ö ÃÖê ¾ÖÖ¯ÖÃÖ »ÖÖî™ü−Öê ¯Ö¸ü...............

†−Öã³ÖÖÖ / ±úß»›ü (¯ÖÖ™üá) / ´Öë ¯Öã−Ö: ŸÖî−ÖÖŸÖ ×úμÖÖ •ÖÖŸÖÖ Æîü ŒμÖÖë׍ú ˆ−֍êú ãÖÖ−Ö ¯Ö¸ü úÖê‡Ô ‹¾Ö•Öß −ÖÆüà פüμÖÖ ÖμÖÖ £ÖÖ …

¾Ö.»ÖêÖÖ ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß (¯ÖÏ¿ÖÖ.)

...................................................................................................................................
úÖμÖÖÔ»ÖμÖ ¯ÖϬÖÖ−Ö ´ÖÆüÖ»ÖêÖ֍úÖ¸ ü(»Öê.¯Ö.) Öã•Ö¸üÖŸÖ, †Æü´Ö¤üÖ²ÖÖ¤ - 380 009.

ÃÖÆüÖ »ÖêÖÖ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß ×¤ü−ÖÖӍú:

†−Öã³ÖÖÖ †×¬ÖúÖ¸üß

ÁÖß/ÁÖß´ÖŸÖß/ãú. ................................................................úÖê †¾ÖúÖ¿Ö ÃÖê ¾ÖÖ¯ÖÃÖ »ÖÖú¸ü †Ö‹ Æîü,

ˆ−Æëü †Ö¯Öêú †−Öã³Ö֐Ö/±úß»›ü (¯ÖÖ™üá)............................´Öë ÁÖß/ÁÖß´ÖŸÖß/ãú´ÖÖ¸üß....................................êú
ãÖÖ−Ö ¯Ö¸ü ¯Öã−Ö: ŸÖî−ÖÖŸÖ ×úμÖÖ •ÖÖŸÖÖ Æîü …

ÃÖÆüÖ. »ÖêÖÖ ¯Ö¸ü߁ÖÖ †×¬ÖúÖ¸üß (¯ÖÏ¿ÖÖ.)

ÃÖ×“Ö¾Ö ÁÖß,
‹. •Öß.†Öò±úßÃÖ
‹»Ö †Ñ›ü Œ»Ö²Ö

´ÖÆüÖê¤üμÖ,

פü. . .200 ÃÖê . .200 ŸÖú ÆüÖê−Öê ¾ÖÖ»Öß †Öê¯Ö−Ö

______________ ¯ÖÏןÖμÖÖêא֟ÖÖ, ___________ ´Öê ´Öî−Öê ³ÖÖÖ ×»ÖμÖÖ ¾ÖÆüÖ
¯Ö¸ü ¯ÖϾÖê¿Ö ±úß ŸÖ£ÖÖ †Ö−Öê •ÖÖ−Öê êú ×»Ö‹ ²ÖÃÖ úÖ ×ú¸üÖμÖÖ Ö“ÖÖÔ Ææü†Ö Æüî, ¤êü−Öê úß é ¯ÖÖ
ú¸êü …

Ö“ÖêÔ úÖ ²μÖÖê¸üÖ ‡ÃÖ ¯ÖύúÖ¸ü Æîü …

²ÖÃÖ úÖ ×ú¸üÖμÖÖ : ºþ. + =

¯ÖϾÖê¿Ö ±úß : ºþ.
: ãú»Ö -

³Ö¾ÖפüμÖ
 OFFICE OF THE PRINCI0PAL ACCOUNTANT GENERAL
(COMMERCIAL & RECEPT AUDIT),
GUJARAT, AHMEDABAD

PROFORMA

APPLICATION FOR ALLOTMENT OF GOVERNMENT QUARTERS / EXCHANGE OF QUARTER.

Note: - Application of the employee of the concerned office must be routed though Administrative Section of
that office.

1. Name and Designation

2. Name of department and officer which working

with section
3. Pay Scale and Present Pay

4. Date of appointment

5. Date Superannuation

6. Details of family members and relation/age

1.
2.
3.
4.
5.
6.
7.
8.
7. Family photograph (in duplicate) of the members who
are residing with his/her in the quarter should be
enclosed with the application and inform any
subsequent changes
8. Whether he/she own a house in Ahmedabad in his / her
own name or in the name of any of the family
members.
9. Whether he/she has drawn HBA from the office:
Details of house purchase/ constructed with the help of
HBA may be furnished.
10 Whether the application’s spouse is employed? If so,
full details of his/her employment may be furnished.
11. Preference if any for quarter of floor preference will be
considered according to administrative convenience.
12. In cases of exchange of quarter, following details may
be furnished.
(i) Present Quarter number

(ii) Reasons for exchange of quarter

(iii) Whether he/she was allowed the exchange of

quarter in the past? If so, give details.
13. Whether he/she was allotted Quarter in past, if so
Quarter Number/Date of allotment. Whether the
quarter was surrendered /get evicted (Mention Date)
14. Any other relevant information not covered in above
mentioned items.

DECLARATION

I hereby declare that the details furnished by me in this application are true: I or any member of my
family does not own a house at the place of my posting. In case of my acquiring a house in my own name or in
the name of my family members, I will properly inform to the Estate Officer. I fully understand that the
allotment to Government. Quarters shall be subject to my signing the agreement. I herby agree to abide by the
terms under which I may be authorized to accuracy the said premises.

Date Signature of government Servant

 INDIAN AUDIT & ACCOUNTS DEPARTMENT
Office of the Principal Accountant General (C&RAudit)
Gujarat, Ahmedabad-380 009

Application for I-card (Serving person)

Name & Designation :-

Date of Birth :-

Valid up to (Date of retirement) :-

Address of Card Holder :-

Station :-

Blood Group :-

Telephone Number/Mobile No. :-

Reason for New I-Card :-

I hereby declare that the particulars given above are correct to the best of my knowledge and belief. I further
declare that I have been/ not been issued with a permanent Identity Card from the office of the Principal Accountant General
(Commercial & Receipt Audit), Gujatrat, Ahmedabad.

SIGNATURE OF APPLICANT

DATE:-

Certify that the particulars and photo have been verified from service record and forwarded for issue of Identity Card.

Sectional Head/Controlling
Officer with Official Seal
 INDIAN AUDIT & ACCOUNTS DEPARTMENT
Office of the Principal Accountant General (C&RAudit)
Gujarat, Ahmedabad-380 009

(Declaration for Retirement Identity Card. (All entries should be in Capital letter only)

Name :-

Address of Card Holder :-

Telephone & Mobile Number :-

Blood Group :-

Date of Birth & Date of :-

Superannuation

Post held on retirement & Pay :-

Scale

Last Pay & Average :-

Emoluments

Qualifying service & pension :-

originally sanctioned

PPO No. & Date :-

I, hereby, declare that the particulars given above are correct to the best of my knowledge and belief. I further declare that I
have been/not been issued with a permanent Identity Card from Principal Accountant General ( Commercial & Receipt
Audit), Gujarat, Ahmedabad.

Date:- (Signature of Applicant)

Certify that the particulars and photo have been verified from service record and forwarded for issue of Identity card.

Sectional Head/Controlling Officer

with official seal
 FORM-I
[See Rule 53(1)]
Nomination for Retirement Gratuity/Death Gratuity when the Government servant has a family and
wishes to nominate one member, or more than one member, thereof

I, _______________________________________ hereby nominate the person/persons mentioned

below who is/are member(s) of my family, and confer on him/them the right to receive, to the extent specified
below, any gratuity the payment of which may be authorised by the Central Government in the event of my
death while in service and the right to receive on my death, to the extent specified below, any gratuity which
having become admissible to me on retirement may remain unpaid at my death.
Original nominee(s) Alternate nominee(s)
Name and address of Relationship Amount Name, address, relationship Amount or
nominee(s) with the Govt. of share of and age of the persons, if any share of
servant/ Age gratuity to whom the right conferred on gratuity
payable to the nominee shall pass in the payable to
each event of the nominee each
predeceasing the Government
servant or the nominee dying
after the death of the
Government servant but before
receiving payment of gratuity

This nomination supersedes the nomination made by me earlier on ___________ which stands cancelled.
Note : i) The Government servant shall draw lines across the blank space below the last
entry to prevent the insertion of any name after he has signed.
ii) Strike out which is not applicable.

Dated this ____ day of ____________ 200 at ______________.

Witnesses to signature:
1. __________________
2. __________________
Signature of Government servant
[To be filled by the Head of Office]
Nomination by :
Designation :
Office :
Signature of the Head of Office
Designation : Sr. Dy. Accountant General
[Admn. & Comml.]
Date
 APPENDIX – V
FORM – I
Form for giving prior intimation or seeking previous sanction under Rule 18(2)
in respect of immovable property
(Other than for building of or additions and alterations to a house)
[GoI. Dept. of Per. & Trg, O.M. No.11013/11/85-Ests.(A), dated 23rd June 1986]

1. Name and designation

2. Scale of pay and present pay
3. Purpose of application-sanction for
transaction/prior intimation of transaction
4. Whether property is being acquired or
disposed of
5. Probable date of acquisition/ disposal of
property
6. Mode of acquisition/ disposal
7. (a) Full details about location viz. Municipal
No., Street/ Village/Talluka/ District and
State in which situated
(b) Description of the property, in the case of
cultivable land, dry or irrigated land
(c) Whether freehold or leasehold
(d) Whether the applicant’s interest in the
property is in full or part (in case of
partial interest, the extent of such interest
must be indicated)
(e) In case the transaction is not exclusively
in the name of the Government servant,
particulars of ownership and share of each
member
8. Sale/purchase price of the property (market
value in the case of gifts)
9. In cases of acquisition, source or sources from
which financed/ proposed to be financed
(a) Personal savings
(b) Other sources, giving details
10. In the case of disposal of property, was
requisite sanction/intimation obtained/ given
for its acquisition? (A copy of the
sanction/acknowledgement should be
attached)
 11. (a) Name and address of the party with whom
transaction is proposed to be made
(b) Is the party related to the applicant? If so,
state the relationship
(c) Did the applicant have any dealings with
the party in his official capacity at any
time, or is the applicant likely to have any
dealing with him in the near future?
(d) How was the transaction arranged?
(Whether through any statutory body or a
private agency through advertisement or
through friends and relatives. Full
particulars to be given).
12. In case of acquisition by gift, whether sanction
is also required under Rule 13 of the CCS
(Conduct) Rules, 1964?
13. Any other relevant fact which the applicant
may like to mention

DECLARATION

I, ____________________________, hereby declare that the particulars given above are true. I request
that I may be given permission to acquire/dispose of property as described above from/to the party whose name
is mentioned in item 11 above.
OR
I, _____________________________, hereby intimate the proposed acquisition/disposal of property by
me as detailed above. I declare that the particular given above are true.

Station : Signature :
Date : Designation :

Note 1. In the above form, different portions may be used according to requirement.
Note 2. Where previous sanction is asked for, the application should be submitted at least 30 days before the
proposed date of the transaction.
 STERILISATION CERTIFICATE

I, Dr. ____________________________________ hereby certify that I have conducted

Vasectomy/Tubectomy operation on Shri/Smt._______________________ husband/wife of Shri/Smt.
____________________________________ employed as
___________________________________________________________________ in Office of the Pr.
Accountant General (Commercial & Receipt Audit) Gujarat, Ahmedabad on ____________________.

02. A sperm count was undertaken on __________________ _________ and on the basis thereof it is certified
that the Vasectomy operation has been completely successful.
[Para – 2 in the case of Vasectomy operation only]

SIGNATURE

UNDERTAKING TO BE GIVEN BY ALL GOVERNMET EMPLOYEES

My spouse have/has undergone Vasectomy/Tubectomy operation at _____________________

___________________________ on ______________. Necessary sterilization certificate issued by Dr.
_____________________________ is enclosed. In case I/my spouse have to take resort to recanlisation for
any reason whatsoever, I undertake to report his fact forthwith to be Government.
02. I also certify that my wife Smt. ____________________________ is not pregnant on this date.

SIGNATURE
 PROFORMA
FAMILY DETAILS REQUIRED TO BE FURNISHED
AS PER GOVERNMENT OF INDIA, MINISTRY OF FINANCE,
OFFICE MEMORANDUM NO.9(16)IV(A)63 DATED 09.01.1964

Sl. Name of the family members Date of His/her relationship with the
No. birth Government servant
(1) (2) (3) (4)
1.
2.
3.
4.
5.
6.
7.

Date : Signature : __________________

Place : Name of Government servant : __________________
Designation : ____________________

Senior Audit Officer/Admn.

Office of the Pr. Accountant General
(Commercial & Receipt Audit) Gujarat, Ahmedabad
Audit Bhavan, Near Iswar Bhavan,
Navrangpura, Ahmedabad – 380 009
 FORM-IV

MEDICAL CERTIFICATE FOR LEAVE

FOR EXTENSION OF LEAVE OR COMMUTATION OF LEAVE

Signature of the Government Servant :_____________________________

I ___________________________________ after careful personal examinatioin of the case hereby

certify that Kum./Smt./Shri _________________________________________ is suffering from
__________________________________________________________ and I consider that a period of absence
from duty of _____________________ days with effect from ____________ is absolutely necessary for the
restoration of his/her health.

Authorised Medical Attendant

Hospital/Dispensary Registered Medical Practitioner
Registration No. : ____________
Date: ____________
FORM-V

Signature of the Government Servant :_____________________________

We, the members of Medical Board

I ___________________________________ Civil Surgeon/ Staff Surgeon/ Authorised Medical

Attendant / Registered Medical Practitioner of _______________________________ do hereby certify that
We/I have carefully examined Shri/Smt./Kum. _____________________ ________________________ whose
signature is given above, and find that he/she recovered from his/her illness and is now fit to resume duties in
Government Service. We/I also certify that before arriving at this decision, we/I have examined the original
medical certificate(s) and statement(s) of the case (or certified copies thereof) on which leave was granted or
extended and have taken these into consideration in arriving at our/my decision.

Members of the Medical Board

1.
2.
3.
Civil Surgeon/Staff Surgeon/
Authorised Medical Attendant/
Registered Medical Practitioner
Date: ____________
NOTE : The original certificate(s) and statement(s) of the case on which the leave was originally granted
or extended shall be produced before the authority required to issue the above certificate. For this purpose, the
original certificate(s) and statement(s) of the case should be prepared in duplicate, one copy being retained by
the Government servant concerned.
 APPENDIX-VII

FORM FOR ADDITION TO FAMILY (IN TRIPLICATE)

01. No.of the Identity Card :

02. Name of the Govt.Servant :

03. Office in which employed :

04. New Additional desired:

Sr. Name Date of Relationship Identification

No. Birth Marks

01.

02.

03.

04.

05. Signature of the Govt.Servant:

06. Signature and Designation of

issuing Authority :

07. Signature of Medical Officer

I/C of the Dispensary :

Date :

Remarks :
Sub-Bill No. T.R. – 25-A/GRA-14-A
(See Rule 66(i) &90 (i) (ii)
TRAVELLING ALLOWANCE BILL FOR TOUR
Note: This bill should be prepared in duplicate – one for payment and the other office copy.

Part-A (To be filled up by Government Servant)

JUNE - 2008
01. Name :
02. Designation :
03. Pay :
04. Headquarters :
05. Details and purpose of journey(s) performed:-
Departure Arrival Mode of Fare Distance Duration of
travel and paid in Kms. halt Purpose
From To class of (Rs.) for road Days Hrs of
Station Date Hrs. Station Date Hrs. accommo- mileage journey
dation

Continued on ……..2…….
 -2-

06. Mode of Journey:

(i) AIR:
(a) Exchange voucher arranged by office : Yes/No
(b) Ticket/Exchange voucher arranged by : Self

(ii) RAIL:
(a) Whether traveling by mail/express/ordinary train ? : --
(b) Whether return tickets available ? : --
(c) If available, whether return tickets purchased ? : --
If not, state reasons.

(iii) ROAD:
Mode of conveyance used i.e. by Government transport by taxi, : --
A single seat in a bus or other public conveyance / by sharing with
Another government servant / in a car belonging to him to third
person to be specified.

07. Date of absence from place of halt on account of –

(a) R.H. and C.L. : --

(b) Not being actually in camp on Sundays and holidays : --

08. Dates on which free board and / or lodging provided by the State or any organization financed by State funds:-

(a) Boarding only : --

(b) Lodging only : --
(c) Boarding and lodging : --
09. Particulars to be furnished along-with hotel receipts etc., in cases higher rate of D.A. is claimed for stay in hotel /
other establishments providing board lodging at scheduled tariffs.

Period of stay Name of the Hotel Daily rate of lodging Total amount paid
From To charge (Rs.) (Rs.)
---------- Not Applicable ---------

Continued on ……...3….
 -3-

10. Particulars of journey(s) for which higher class of accommodation than the one to which the Government servant is
entitled was used:-

Name of Places Mode of Class by which Class to which Fare of the

Date From To conveyance entitled traveled entitled class
used
-------- Not Applicable -------

If the journey(s) by higher class of accommodation has been performed with the approval of competent authority, number and
date of the sanction may be quoted.

11. Details of journey(s) performed by road between places connected by Rail:

Date Name of places Fare paid Remarks

From To
--------------------------------Not applicable ----------------------

12. Amount of T.A. advance, if any drawn. : Rs.

Certified that the information, as given above, is true to the best of my knowledge and belief.

( )
Signature of Government Servant
Date:

Continued on ….4….
 -4 -

PART – B (To be filled in the Bills Section)

01. The net entitlement of account of Traveling Allowance works out to Rs. ………………… as detailed below:

(a) Railway / Air / Bus / Steamer fare : ………………………..

(b) Road mileage for ……………………..Kms. @ Rs. ……………………… per Kms.
Rs. Ps.
(c) Daily allowance per day:

(i) …………………. Day @ Rs. …………………………...

(ii) ………………….. Day @ Rs. …………………………...

(iii) …………………...Day @ Rs. …………………………...

(iv) ………………… Day @ Rs. …………………………...

(d) Actual Expenses

(i) ……………………………………………………….

(ii) ……………………………………………………….

(iii) ………………………………………………………

(iv) ……………………………………………………….

Gross amount Rs.

(e) Less amount of T.A. advance, if any drawn vide voucher

No. ………………………………dated …………………………

2. The Expenditure is debatable to …………………………

…………………………………………….
Initial of Bill Clerk Signature of the D.D.O.

Countersigned

................................................................................
Signature of the Controlling Officer
 RAILWAY CM257
RESERVATION/CANCELLATION REQUISITION FORM
If you are a Medical Practitioner Please tick ( ) in Box Dr.
(You could be of help in an emergency)
If you want Sr. Citizen concession, please write Yes/No in box
(if yes, please carry a proof of age during the journey to avoid
inconvenience of penal charging under extant Railway Rules)

Do you want to be upgraded without any extra charge? Write Yes/No in the box.
(If this option is not exercised, full fare paying passengers may be upgraded automatically)

Train No & Name ___________________________ Date of journey__________________

Class _________________________ No of Berth/Seat______________
Station from ____________________________ To ______________________________
Boarding at _______________________ Reservation upto _______________________
Name in Block letter(not more Choice if any
S.No. Sex(M/F) Age Concession/TravelAuthority No.
than 15 chars)
1. Lower/Upper berth

2. Veg./Non-veg. Meal for

3. Rajdhani/ Shatabdi Express
Only
4.
5.
6.

CHILDREN BELOW 5 YEARS (FOR WHOM TICKET IS NOT TO BE ISSUED)

S.No. Name in Block Letters Sex Age

ONWARD/RETURN JOURNEY DETAILS

Train No. & Name_______________________________ Date ________________________

Class ________ Station from:_____________________________
To_____________________________
Name of applicant _______________________________________________________________
Full Address ____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

Signature of the Applicant/Representative

Telephone No., if any ____________________________ Date ________________Time ________________
FOR OFFICE USE ONLY
S.No. of Requistion_______________________________ PNR No.______________________________________
Berth/Seat No.___________________________________ Amount collected ______________________________
Signature of Reservation Clerk
Note : 1.Maximum permissible passengers is 6 per requisition.
2. One person can give one requisition form at a time.
3. Please check your ticket and balance amount before leaving the window.
4. Forms not properly filled or in illegible forms shall not be entertained.
5. Choice is subject to availability