Application Form For Reimbursement Of Residential Telephone / Mobile / Broadband Charges

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Annexure – I
APPLICATION FORM FOR REIMBURSEMENT OF
RESIDENTIALTELEPHONE / MOBILE / BROADBAND CHARGES
(To be filled by the Officer claiming reimbursement)
(Part A)
NAME
Bank A/c No.
DESIGNATION
TELEPHONE Nos.
BILL No.
DATE
PERIOD
AMOUNT
FROM
TO
Tel.
Mob
Broadband
YES
NO
GRAND TOTAL
Admissible amount claimed for Landline/Mobile/Broadband charges
The bills, in original with call details, are enclosed for reimbursement.
Dated
Signature of the user official
(Part B)
G.A. Section
To be filled by G.A. Section
Passed Amount
Remarks
The bills are in order and may be passed for payment. J.D.(E) may kindly sign the Pay Order.
A.D.(GA)
J.D.(GA)
J.D.(E)
(Part (C)
Pay Rs.__________(Pay rupees__________________________________________________)
(Drawing & Disbursing Officer)

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