ZOHO CORPORATION PVT LTD

ESTANCIA IT PARK, NO 140, 151, GST ROAD, VALLANCHERI VILLAGE, GUDUVANCHERY,

CHENNAI - 603202

Reimbursement Claim Form

Date: 17 Nov 2017

Name: JAYAKUMAR J Employee No: 2958

Claim Date: 17 Nov 2017 Claim No: 18434

Sl No Item Bill No Bill Date Amount

1 MEDICAL REIMBURSEMENT 02 Aug 2017 85.00
2 MEDICAL REIMBURSEMENT 03 Oct 2017 250.00
3 MEDICAL REIMBURSEMENT 26 Jul 2017 3,010.00
4 MEDICAL REIMBURSEMENT 09 Nov 2017 942.00
5 MEDICAL REIMBURSEMENT 28 Aug 2017 50.00
6 MEDICAL REIMBURSEMENT 29 Jul 2017 84.00
7 MEDICAL REIMBURSEMENT 13 Dec 2016 5,000.00
8 MEDICAL REIMBURSEMENT 17 Oct 2017 470.00
9 TELEPHONE REIMBURSEMENT 17 Oct 2017 300.00
10 TELEPHONE REIMBURSEMENT 17 Oct 2017 470.00
11 TELEPHONE REIMBURSEMENT 19 Aug 2017 613.00
12 MEDICAL REIMBURSEMENT 19 Aug 2017 234.00
13 TELEPHONE REIMBURSEMENT 05 Nov 2017 301.00
14 TELEPHONE REIMBURSEMENT 05 Nov 2017 695.00
Total: 12,504.00
Amount in words: Rupees Twelve Thousand Five Hundred Four
Remarks:

Employee Signature: Date:

Nov 17, 2017 7:08 PM