APPLICATION FOR REIMBURSEMENT OF MEDICINES PUCHASED BY PENSIONERS
DURING MARCH 2020 TO MAY 2020
The Dy. General Manager ( B & O ),
State Bank of India,
_
_
(
_____________________ Administrative Office,
_______________________________________
Respectfully submitted through the Medical Officer, ______________________Dispensary)
Madam / Dear Sir,
I submit herewith the bills for reimbursement of expenses incurred by me on medicines
th
purchased from outside, in terms of Mumbai (Metro) L H O letter No. 0067 of the 6 May,
2
020. I give my details for your kind consideration.
Name of the pensioner / family
pensioner & PF Index No.
Mr / Mrs / Ms ________________________________
PF Index No. ____________
1
2
Pension Paying Branch & RBO
_
_______________________, RBO _______________
3
4
5
6
7
Dispensary registered with
Regn. No. with the dispensary
Reimbursement claimed for
Self / Spouse
Name of Spouse (if claimed for spouse)
Details of Medicines purchased :
Date of Cash Bill
/
Supplier’s Name
Amount
(Rs.)
Memo
Memo No.
Total - Rupees
only
Certified that I have actually incurred the above expenses which may be reimbursed &
credited to my pension A/c No. __________________.
Place : _______________
Date : ___ / ___ / 2020
__________________________________________________________________________
For Use of Medical Officer
( Claimant’s Signature )
_
I have scrutinized the above claim & found to be as per the case paper of the pensioner.
Entry made in the Pensioner’s Case Paper.
Date : ___ / ___ / 2020.
Medical Officer