<p>FEP REIMBURSEMENT FORM</p><p>Name______Rmb. for the Month/s______</p><p>Employee Code______Location______</p><p>Band & Designation______Unit______</p><p>BOOKS AND PERIODICALS** Amount Cash Memo/ Bill S.No. Bill Date Type of Book / Journal No. Rs. P. 1 2 3 4 5 Total (Rs.)(a)</p><p>MEDICAL REIMBURSEMENT** Amount Cash Memo/ Bill Relationship of patient S.No. Bill Date No. with Employee Rs. P. 1</p><p>Total(Rs.)(b)</p><p>VEHICLE RUNNING AND MAINTENANCE** Amount S.No. Accounts Head Rs. P. 1 Petrol Expenses</p><p>2 Vehicle Repair & Maintenance</p><p>3 Driver Salary*</p><p>4 Insurance</p><p>5 Any Other</p><p>Total(Rs.)( c) </p><p>Grand Total (Rs.) (a+b+c) Total(Rs.) (In words)Rs.</p><p>I declare that the reimbursement claimed on this mail is against bonafied expenses actually incurred by me for self/ family as defined in the scheme.</p><p>(Signature of Employee) Date: *attach the receipt for driver salary along with the form. ** attach the original bills along with the form in the order heads are mentioned above.</p>