FORM

REIMBURSEMENT CLAIM AS PER SECTION 12 (1) (C) OF THE RIGHT OF

CHILDREN TO FREE AND COMPULSORY EDUCATION ACT, 2009 AND TAMIL
NADU RIGHT OF CHILDREN TO FREE AND COMPULSORY EDUCATION
RULLES 2011.

(See Return Statement Submitted by the DEEO/DEO/IMS as per G.O Ms. No. 60 School Education
(X2) Department dated 01.04.2013)

Claim for the Academic Year :

Name of the school :

UDISE Code :

Address :

Telephone Number with STD Code :

Name of the Principal/Head of the

Institution :

Whether the school is under the Regulatory : DMS DSE DEE

Jurisdiction of (Mark)

Board of Affiliation : State Board of the Tamil Nadu / CBSC / ICSE

1 Number of Section In the class (*)
LKG UKG I II II IV V V VII VIII
I I
2 Total No. of seats in the class (* x 30)
For LKG to V and (x*35) for VI to VIII

3 Number of seats under 25% reservation

for Disadvantaged Group / Weaker Section

4 Number of Children admitted under 25%

reservation for Disadvantaged Group /
Weaker Section**

5 Out of SI. No. 4 Number of children for

whom necessary certificates obtained.

6 Number of unfilled seats under 25% for

Disadvantaged Group / Weaker Section

7 Number of children dropped out. If any

8 Number of children for whom the present

Claim is preferred (SI. No.4 minus SI. No.7)

9 Number of Children for whom the claim is

Preferred in the previous Year.(2013-14,
2014-15, 2015-16) LKG UKG I II III I V VI VI VII VIII
V I

** List of children admitted to be submitted in the Performa enclosed duly signed by the
Correspondent and Principal)
10. Fees (Rule 9(1) of TN RTE Rules.2011)

a) Fee Determined by the private (Amount in Rupees)

Schools Fee Determination Committee as
LKG UKG I II III I V VI VII VII
per Tamil Nadu
V
Schools (Regulation of Collection
Of Fees) Act 2009 for the class

b) Per - child cost fixed by the

Government for the class LKG UKG I II III I V VI VII VII
V

c) Actual Fees Collected from the

Children in the class
LKG UKG I II III I V VI VII VII
V

d) Least amount among

10(a) / (b) /(c)
LKG UKG I II III I V VI VII VII
V

Class No. Of students (Si. No.8) Claim amount per child Total Amount
(SI. No.10(d)) Rs.
Rs.
(1) (2) (3) (4)
LKG
UKG
1
2
3
4
5
6
7
8
Total

Total Claim Rs. One Lakh Sixty Eight thousand Seven

hundred rupees only
10. BANK DETAILS.
(Separate Bank Account in a Nationalized Bank to be maintained exclusively for RTE Act)
Name of the Bank :
Branch Name :
Place of Bank :
Bank Account No :

Beneficiary Name :
Bank IFSC Code No :
Bank MICR No :

Bank Account – to be in the Designation of the Principal with Schools name

NOTE: attached the bank pass book Xerox copy

Certificate

1) The information given above are true to the best of my knowledge and belief.
2) Certified that no fee has been collected on behalf of the children admitted under RTE Act
from Parent / Guardian or from any for whom the claim is made.
3) Certified that this is the actual and final claim made with reference to the TN RTE Rules
2011 – Rule 9(1)
4) Certified that there is no dropout of children admitted under 25% reservation and those
children are continuing their studies in age appropriate class.
5) Certified that the details of children below have dropped out due to the reasons mentioned as
below:

Sl.N Name o f the child Class Discontinued Reasons

o date
1

3
 4

6) Certified that these children are not subjected to any kind of discrimination or forced to pay
the fees.
7) Certified that the claim for reimbursement of Rs. 1,68,779 Correct
8) Certified that if the reimbursement claim is found to be false or incorrect at any stage or
objected in the audit. I will refund the entire amount in one lump sum to the Government.

Signature of the Principal/ Headmaster Counter signature of the correspondent

Name: A.Vengdachalapathy
Date :
Signature of inspecting/Verification Officer

(DEEO / DEO/ MS)

 Form – IV
Return Statement to be submitted to the DEEO / DMO / IMS for the year 2015-2016

Name of the school :

Address :
Telephone No. :
Name of the Principal/ Head of the Institution:

Entry level class

Total No. Of seats in entry level class

Total No. Of seats under 25% Reservation

For Disadvantaged / Weaker section

Admission made under 25% Reservation for

Disadvantaged/ Weaker Section Remarks

Bank Name and branch with IFSCode

Bank Account No. Of the school

Beneficiary Name

Signature of the Principal / Head of the institution

 ** PROFORMA-2
Name list of children admitted under RTE act to be annexed (2016-17)
Name of the school:Dr.V.Gengusamy Naidu Nursery & Primary School- Vaiyampatty
S.no Name of the child Class Date of birth Father’s / Guardian’s Name
1 S.LATHIKA SREE LKG 27.02.2012 P.Ramachandran
2 S.ABI ROSHARI LKG 04.10.2012 Stephen Charles
3 R.PRANESH LKG 20.10.2012 Rajakumar
4 A.HAREESH LKG 22.02.2013 Alaxander
ABIRAHAM
5 G.DHANUSH SREE LKG 16.10.2012 P.Ganeshan
6 M.DHARANIKA LKG 15.09.2012 P.Muthukumar
7 R.SIVA PRAKASH LKG 01.10.2012 Ramesh
8 G.PRIYADHARSAN LKG 27.02.2013 K.Gopal
9 A.AFBSHARA LKG 19.12.2012 S.Arif Ali
10 S.ANU PRABHA LKG 18.08.2012 G.Saravanan
11 M.PRAVEEN LKG 30.12.2011 K.V.Murugesan
KUMAR
12 R.SELVAKUMARAN LKG 19.01.2013 Ramasamy
13 S.MITHRA DEVI LKG 18.05.2013 K.Saravanan
14 B.SASIDHARAN LKG 28.10.2012 Baladhandayuthapani
15 R.KISHAN LKG 22.09.2012 Arumugam
16 V.SANJU LKG 08.05.2013 Velmurugan
17 LKG
18 LKG
19 LKG
20 LKG
21 LKG
22 LKG
23 LKG
24 LKG
25 LKG

Signature of the Principal counter signature of the correspondent

Name
Date
Inspecting / verification officer

**PROFORMA-2
Name list of children admitted under RTE act to be annexed (Those who
Have admitted in 2015-16 now studying UKG)
Name of the school: Dr.V.Gengusamy Naidu Nursery & Primary School - Vaiyampatty
Sl.no Name of the child Class Date of birth Father’s / Guardian’s Name
1 M.PAVITHRA UKG 05.04.2012 M.MURUGESH
 2 K.HASHINI UKG 23.10.2011 S.KUMAR
3 A.A.TAMILARASA UKG 09.01.2012 S.R.ANANDHAN
N
4 M.MALAIKANNAN UKG 22.05.2012 K.MALAIYAPPAN
5 K.SAIKRISHNA UKG 05.05.2012 P.KANNAN
6 S.MOHAMED ASIF UKG 15.08.2011 A.SATHIKBATCHA
7 R.RANJANA SREE UKG 22.08.2012 P.MANICKA VEL
8 V.SAISARAN UKG 19.04.2012 K.VIJAYAKUMAR
9 D.KAVINRAJ UKG 30.03.2011 P.DURAIRAJ
10 S.MOHAMED UKG 03.11.2011 T.SULDHAN AMEERDEEN
MUSTHAPA
11 R.MANIKANDAN UKG 25.09.2011 P.RAMASAMY
12 G.PRADEEPA UKG 24.10.2011 GOPI
13 S.SOPHIYA UKG 15.09.2011 SADHA SIVAM
14 UKG
15 UKG
16 UKG
17 UKG
18 UKG
19 UKG
20 UKG
21 UKG
22 UKG
23 UKG
24 UKG
25 UKG
26 UKG

Signature of the Principal counter signature of the correspondent

Name
Date
Inspecting / verification officer

**PROFORMA-2
Name list of children admitted under RTE act to be annexed (Those who
Have admitted in 2015-16 now studying 1ST STD)
Name of the school:
Sl.no Name of the child Class Date of birth Father’s / Guardian’s Name
1 P.S.VARSHANA 1st STD 11.03.2011 P.SUBRAMANIYAN
2 R.SABRIN 1st STD 04.02.2011 P.RASID
3 S.SIRAJUDEEN 1st STD 19.10.2009 SATHIK BATCHA
4 G.VAISHNAVI 1st STD 08.04.2011 GOPAL
5 P.VISHALINI 1st STD 08.04.2011 S.PARTHIBAN
6 K.YASVANTHIKA 1st STD 15.09.2010 K.KUMARESAN
A
7 1st STD
8 1st STD
9 1st STD
10 1st STD
11 1st STD
 12 1st STD
13 1st STD
14 1st STD
15 1st STD
16 1st STD
17 1st STD
18 1st STD
19 1st STD
20 1st STD
21 1st STD
22 1st STD
23 1st STD
24 1st STD
25 1st STD
26 1st STD

Signature of the Principal counter signature of the correspondent

Name
Date
Inspecting / verification officer
**PROFORMA-2
Name list of childred admitted under RTE act to be annexed (Those who
have admitted in 2015-16 now studying IIST STD)
Name of the school:
Sl.no Name of the child Class Date of birth Father’s / Guardian’s Name
1 IIst STD
2 IIst STD
3 IIst STD
4 IIst STD
5 IIst STD
6 IIst STD
7 IIst STD
8 IIst STD
9 IIst STD
10 IIst STD
11 IIst STD
12 IIst STD
13 IIst STD
14 IIst STD
15 IIst STD
16 IIst STD
17 IIst STD
18 IIst STD
19 IIst STD
20 IIst STD
21 IIst STD
22 IIst STD
23 IIst STD
 24 IIst STD
25 IIst STD
26 IIst STD

Signature of the Principal counter signature of the correspondent

Name
Date
Inspecting / verification officer