FEP REIMBURSEMENT FORM

Name______________________________

Rmb. for the Month/s__________________________

Employee Code______________________

Location____________________________________

Band & Designation___________________

Unit________________________________________

BOOKS AND PERIODICALS**

S.No.

Cash Memo/ Bill

No.

Amount
Bill Date

Type of Book / Journal

Rs.

P.

1
2
3
4
5
Total (Rs.)(a)

MEDICAL REIMBURSEMENT**
S.No.

Cash Memo/ Bill

No.

Bill Date

Relationship of patient
with Employee

Amount
Rs.

P.

Total(Rs.)(b)

VEHICLE RUNNING AND MAINTENANCE**

S.No.

Amount
Rs.
P.

Accounts Head

Petrol Expenses

Vehicle Repair & Maintenance

Driver Salary*

Insurance

Any Other
Total(Rs.)( c)

Grand Total (Rs.) (a+b+c)

(In words)Rs.

Total(Rs.)

I declare that the reimbursement claimed on this mail is against bonafied expenses actually incurred by me for self/
family as defined in the scheme.

(Signature of Employee)
*attach the receipt for driver salary along with the form.
** attach the original bills along with the form in the order heads are mentioned above.

Date: