Form C: NONGPF/WB/20171123114956897/1/5 Sudipta Das
Form C: NONGPF/WB/20171123114956897/1/5 Sudipta Das
Form C: NONGPF/WB/20171123114956897/1/5 Sudipta Das
FORM C
Application Form for settlement of claim for reimbursement
under the West Bengal Health Scheme, 2008
(See sub-clause (1) of clause 12)
(To be filled in by the applicant)
3. Full Address:
(i) Office :
NONGPF/WB/20171123114956897/1/5
SUDIPTA DAS
LECTURER
13.Disease : THALASSEMIA
West Bengal Health Scheme, 2008
DECLARATION
I hereby declare that the statements made in the application are true to the best of my
knowledge and belief and the person for whom medical expenses were incurred is wholly
dependent on me. I am a beneficiary of the West Bengal Health Scheme, 2008, and the
enrolment under the Scheme was valid at the time of treatment. I agree for the reimbursement
as is admissible under the rules.