Details of all the children of the employee:

 10. Academic year, Name of School/Residential School and Class in which children studied:

11. Distance of Hostel of child from residence of employee ( in case Hostel Subsidy is claimed)…..
12. Amount of CEA/Hostel Subsidy already received up to previous quarter:___…
13. The Academic year for which CEA /Hostel Subsidy is applied now: ..
14. (a) Whether the child for whom the CEA is applied for is a disabled child: YES/NO
(b) If yes, indicate the nature of disability:
(c) Date of disability certificate.
(d) Indicate the percentage of disability:
15. Whether the Bonafide certificate from Head of Institution has been attached : Yes/No.
16. For Hostel Subsidy, the Bonafide certificate from mentioning the amount is attached: Yes/No

17. If Yes at Item No. 16, Amount claimed for Hostel Subsidy:……………….
18. (i) Certified that the fee/amount indicate above had actually been paid by me.
(ii)Certified that my wife/husband is/is not a Central Government Servant.
(iii)Certified that my husband/wife Sri/Smt:………………………… is presently working
as : ……………………… in …………………..and that he/she shall not apply/has not applied for the Children Education Allowance for the child mentioned above.
(iv) Certified that I or my wife/husband has not claimed this re-imbursement from any other source and will not claim the same in future.
17 Certified that my child in respect of whom reimbursement of Children Education Allowance is applied is studying in the School/Jr. College which is recognized and affiliated to Board of Education/University.

18. The information furnished above are complete and correct and I have not suppressed any relevant information. In the event of any change in the particulars given above which affect my eligibility for reimbursement of Children Education Allowance, I undertake to intimate the same promptly and also to refund excess payments if any made. Further, I am aware that if at any stage the information/documents furnished above is found to be false, I am liable for disciplinary action.

Signature:
Name:
Design & Station
Working Under:
Date:

The family composition of the claimant has been verified from the official records such as Pass Declaration/Register etc and found correct.

Date:

Signature of Sr. Subordinate
With office seal and stamp

FOR OFFICE USE ONLY

Sl. No.	Name of staff	P.F.No.	CEA Amount	Hostel Subisdy Amount if any	Total

Sl. No. Name of staff P.F.No. CEA Amount Hostel Subisdy Amount if any Total

Forwarded to : Sr.DFM/CKP for vetting and early return.

Bill Clerk/OS

Bill Compiling Officer

Annexure ‘B’

BONAFIDE CERTIFICATE FROM THE HEAD OF INSTITUTION/SCHOOL

This is to certify that Master/Baby/Mr./Miss …………………………Roll no…………………. Admission No……………………son of Sri/Smt…………………………is a bonafide student of this school and studied in Class……….……. during the financial year ………………………….. and as per School records his/her date of birth is ………………….………………. in words ………………………This is to also certify that the above named child had studied in this school in the previous academic year………………………….

He/She bears a good moral character.

** During the year Master/Baby/Mr./Miss……………………………had resided in the residential complex (Hostel) of the school and paid an amount of Rs………..…………….. toward boarding and lodging in the residential complex.

This Institution/School is affiliated recognized by ………………………………and the affiliation/recognition Number is……………………

Dated:
Place:
Signature Head of the Institution/School
(with Stamp and seal)

**(Strike out it is not applicable)