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Form For Reimbursement of Tuition Fee

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FORM FOR REIMBURSEMENT OF TUITION FEE

Certified that the child/children mentioned below in respect of whom reimbursement of Tuition Fee is claimed is/are
wholly dependent upon me.
NAME OF THE CHILD SCHOOL IN WHICH CLASS IN MONTHLY TUITION FEE AMOUNT
& DATE OF BIRTH STUDING WHICH TUITION FEE ACTUALLY REIMBURSEMEN
STUDDING ACTUALLY PAID T CLAIMED
PAYABLE

2. Certified that the Tuition fees indicated against the child/each of the children have actually been paid by i.e.
Vide fee receipt and certificate (s) from the institution (s) attached.

3. Certificate that i) My Wife/Husband is in Indian Institute of Science service


ii) My wife/husband is/ is not in Indian Institute of Science service and Her/His pay does not
exceed Rs. 1,200/- in the pre-revised scale but She/he will not claim reimbursement of tuition
fee in respect of our child/children.
iii) My wife/husband is employed with ………………………………………………….. she/he is
not entitled for reimbursement of tuition fee in respect of our child/children.

4. Certified that during the period covered by this claim/the child/children attached the school (s) regularly and did
not absent himself/herself themselves from the school (s) without proper leave for a period exceeding one
month.

5. Certified that the child/children mentioned above has/have not been studying in the same class for more than two
years.

6. Clarified that I or my wife/husband have/has not claimed and will not claim the children’s educational allowance in
respect of the children mentioned above.

7. In the event of any change in the particulars given above which affect my eligibility for reimbursement of tuition
fees I the undersigned to intimate the same promptly and also to refund excess payments if any made.

8. Certified that I am claiming Tuition fees for my first/second child. Whose name has been declared in the family
particulars.

SIGNATURE…………………………………………

NAME………………………………………………...

DESIGNATION………………………………………

DEPARTMENT………………………………………

EMPLOYEE CODE No………………………………


(Name and Location of the Institution)
1. Certified that the Information furnished by Mr/Mrs ………………………………………………………………… that
Sl No. 4 and 5 overleaf are correct.

2. Certified that Shri/Kumari ………………………………………………………………………………… Son/Daughter


of Shri/Smt…………………………………………………………………………………………….. passed out from
class in……………………………. He/She had paid Tuition fees for the period from ………………….. to
……………... as per details given below.

1. Tuition Fees Rs……………………………..


2. Science Fees Rs…………………………….
3. Music Fees Rs………………………………

3. Certified that Shri/Kumari…………………………………………………………………………….. is at present a


student of class………………………………………………………………. and had paid Tuition fees for the period
from…………………. to……………………… as detail given below.

1. Tuition Fees Rs…………………………….


2. Science Fees Rs…………………………….
3. Music Fees Rs………………………………

4. Certified that this is a school/College run by Central Government / State Government / Union Territory /
Administration / Municipal Committee / Panchayat Samithi / Zilla parishad.

5. Certified that this is a school / college recognized by the educational authorities of……………………………….
State/Union Territory administration.

6. Certified that the fee structure has been approved by the education Department, Government of
…………………………………………

Principal/Headmaster/Headmistress
Date:……………………

(Stamp of the Institution)

(Strike out whichever is not applicable)

INDIAN INSTITUTE OF SCIENCE


BANGALORE – 560 012
FOR OFFICE USE ONLY

DEBIT ………………………………………………………………… Dept/Salaried/Estiblishment

Tuition Fees Registered folio……………………………………….

Passed for payment for Rs………………………………………………………………………………..

SUPID DEPUTY FINANCIAL INTERANAL AUDIT


CONTROLLER

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