From Director General Elementary Education, …

1 FromDirector General Elementary education , haryana , shiksha Sadan, Sector-5, Elementary education Officer, haryana No. 22/33-2013 HR C& V (4)Dated, Panchkula, the 3 3 Sub:- Punjab Medical Attendence Rules, Dependents on State , Wives/SistersPlease refer on the subject cited Punjab Medical Attendence Rules, vide Health Department, HaryanaInstruction HB-II dated , the following documents / affidavits arerequired with Medical Re-imbursement Bills / Claims :Deponent self affidavit in case of self medical re-imbursement claim(Annexure-A).For dependent members medical re-imbursement claims except wife Affidavit& Income Certificate (Annexure-B). The dependent's re-imbursement claimwould be duly verified by the concerned District Elementary education abovee U---Supritendent HRC&VFor Director General Elementary Education, CA haryana , PanchkulaToD:\HRC&V\(4) RANA SIR (4) \ LETIIR - RANA (SELF)I S/o R/o Working as in school District I the above named deponent do hereby solemnly affirm anddeclared as under:-That the depondent is claiming the present medicalreimbursement claim from the neither the deponent has received any claim from anyinsurance in case, any claim/information is found incorrect.

2 I shall beready to face criminal proceeding and departmental I shall be solely held responsible for any financial fraud, ifcommitted in this regard in whatsoever : DeponentPlaceVERIFICATION It is verified that the contents of Para No. 1 to 4 of the above are to be true and correct to my knowledge. Nothingrelevant has kept concealed : DeponentPlaceAFFIDAVIT S/o R/o DistrictWorking as in school I the above named deponent do hereby solemnly affirm anddeclared as under:-That my wholly dependent father/mother/ ison/daughter issolely dependent on me and is residing with my wholly and solely dependent father /mother / -/son/daughter is having income not more than permonth income which includes income from any source vizagriculture/private sector, commission, interest, privateemployment and royalty income neither me nor my wholly & Solely dependentfather/mother/ , J/son/daughter has received any claim fromany employer nor from any insurance company in what so in case, any claim/information is found incorrect, I shallbe ready to face criminal proceeding and That I shall be solely held responsible for any financial fraud.

3 Ifcommitted in this regard in whatsoever manner and I shalldeposit the amount claimed along with interest in the : DeponentPlaceVERIFICATIONIt is verified that the contents of para No. 1 to 5 of the above myaffidavit are to be true and correct to my knowledge. Nothing relevanthas kept concealed Elementary education OFFICERIt is certified that I have verified the contents of affidavit andincome certificate submitted by Sh/Smt. Designation Serving in school in regard to solely & wholly dependent's medical claim of S/o Relation . As per verification the case isgenuine one and the same is recommended for Elementary education Officer