CGHS: Medical Reimbursement Claim Form for Pensioners

CGHS: Medical Reimbursement Claim Form for Pensioners

Annexure-I

Draft for Affidavit for Duplicate Claim Papers/bills on stamp paper

I ............................Son/wife/daughter of ......................and resident of ..........................have lost/misplaced the original paper or the same are not traceable.I hereby give an undertaking that i have not received any payment against the original bills/claim papers from any source and that if the origina; papers are traced.I shall not stake claim against original bills in future and that in the event.I receive any cheque against the original bills in future,i shall return the same to competent authority.

Deponent

Verified by Notary Public

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