Joint Declaration Form

We (1) ___________________________________________________________________________________
(Name, Designation, Office & Department of the Applicant) and (2) _____________________________
__________________________________________________________________ (Name, Designation, Office &
Department of spouse) hereby declare that we will claim all the Medical Reimbursement Expenses, Children
Education Allowance and Leave Travel Concession in respect of ours and our family members from the Office /
Department of _____________________________________________________________________________
_________________________________________________________________________________________.
DEPENDENT FAMILY MEMBERS
Sl Name Date of Birth Relation
1

Signature of Applicant Signature of Spouse

Name of Applicant Name of Spouse

Designation Designation

Office & Department Office & Department

Signature of Competent Signature of Competent

Authority Authority

Office Seal Office Seal

Date Date