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:-
8. 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 any other 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.: ……………………………………….
Children Education Allowance Performa
