MEDICAL REIMBURSEMENT BILL PREPARATIO

INSTRUCTIONS
1. Go to DATA Sheet

2. find the fallowing heads and enter the data in the relavant fields and select SAVEAS option and save the file with 1.DATA OF THE EMPLOYEE FOR MEDICAL REIMBURSEMENT BILL PROPOSALS II.PERTICULARS FOR BILL CLAIM AFTER SANCTIONING THE AMOUNT BY AUTHORITIES 3. For midical reimbursement bill proposals enter the data in the 1st head

print the sheets in the order 1.proceed , 2.CHECKLIST ,3.CHECKLIST2,4.APPENDIX 5.APPLICATI

4. After the proposals are accepted and the sanctioning of the bill ,enter the data under 2nd head and print 5. submit the bills to the treasury

gandhamneni@gmail.com

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MENT BILL PREPARATION

SAVEAS option and save the file with your name BILL PROPOSALS

AMOUNT BY AUTHORITIES

KLIST2,4.APPENDIX 5.APPLICATION FORM, 6,NON DRAWL -DEPENDENT CERITFCATE

he data under 2nd head and print the sheets from " f58" to "back47" sheets

by Sreenivas Gandhamaneni School Asst (Maths) Govt.High school No.1 Old Town ,Anantapur- 515001

logspot.com

cell :-99594 22002 - 94402 69989

1.DATA OF THE EMPLOYEE FOR MEDICAL REIMBURSEMENT BILL PROPOSALS

PARTICULARS
S.NO 1 2 3 4

II.PERTICULARS FOR BILL CLAIM AFTER SANCTIONING THE AMOUNT BY AUTHORITIES BANK A/C DDO CODE AND A/C NO 1003567-0092 DIST TREASURY OFFICE ANANTAPUR 123456 DTO 80 SBI

NAME

EMP ID

NAME OF THE EMPLOYEE NAME OF THE DEPENDENT-AGE

SELF OR RELATION SHIP WITH EMPLOYEE

Sri smt

Y.Gangi Reddy resma wife of

S.G.T

11111234567

123456789023 IF ,SELF DO NOT ENTER iN THIS COLOR BOXES

TREASURY OFFICE TREASURY PLACE - CODE SALARY BANK NAME BANK PLACE-CODE
PROCEEDIN RC NO OF BILL SANCTIONING AUTHORITY & DATE

w/o EDN SECTIOM

STATE BANK OF INDIA B.K.SAMUDRAM

DESIGNATION AND SECTION

5 6 7 8 9

SCHOOL/OFFICE PLACE Mandal DISTRICT RESIDENTIAL ADDRES

MPUP SCHOOL CHADULLA SINGANAMALA Anantapur .Dt Mandal Anantapur MP

R.C.No.5601/B5/2007 8660

AMOUNT SANCTIONED

eight thousand six hundred and sixty only

D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur Residence Sever Attrition,Badly decayed teeth Consultation.Root canal treatment,Ceramic crowns 10/10/2009 Dentocare Super Speciality Hospital Anantapur DR.M.Venkata Krishna Murthy 1 8660 BAISC 7970 DA 4805 HRA 797 CCA 80 IR 1753 100 Rupees eight thousand six hundred and sixty only O/A 300 TOTAL 15705 M.E.O M.P.P B.A,B.Ed M.P.SINGANAMALA PAY SCALE 5750--13030 Referal 10/20/2009

by Sreenivas Gandhamaneni School Asst (Maths) Govt.High school No.1 Old Town ,Anantapur- 515001 cell :-99594 22002 - 94402 69989

ILLNESS FELT AT 10 RESIDENCE/OTHER PLACE

11 12 13 14 15 17 19 20 21 22 23 24

SUFFERING FROM TREATMENT GIVEN DURATION OF TREATMENY HOSPITAL NAME & REGD NO PLACE AND TYPE OF HOSPITAL DOCTOR NAME-REFERED DOCTOR NO of CONSULTATION and FEE HOSPITAL EXPENDITURE PAY OF THE EMPLOYEEE RS RS

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DRAWING OFFICER DDO OFFICE- PLACE Sri

MANDAL EDUCATIONAL OFFICER

MANDAL PRAJA PARISHAD

DRAWING OFFICER NAME & 25 QUALIFICATION SANCTIONING OFFICER- OFFICE PLACE

H.kadirappa

DIST.EDUCATIONAL OFFICER

O\O D.E.O

ANANTAPUR

26

27

PROCEEDINGS RC-NO OF DDO

335/2009/B

11/12/2009

From Sri/Smt H.kadirappa

B.A,B.Ed

To,
DIST.EDUCATIONAL OFFICER O\O D.E.O ANANTAPUR

MANDAL EDUCATIONAL OFFICER M.P.SINGANAMALA

Rc.No:- 335/2009/B Respected sir, Sub:-

Date:- ########

API Medical Attendence Rules-Medical Reimbursement bill of Rs 8660/- pertaining of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL,CHADULLA, SINGANAMALA Mandal, Anantapur .Dt -proposals submitted - orders -requested -Regd

Ref:-

1). G.O.M.S.No.105,HM & FW ,Dated 09-04-07 of Govt of Andhra Pradesh,A.P, Hyderabad 2). G.O.M.S.No.74,HM & FW ,Dated 15-03-05 of Govt of Andhra Pradesh,A.P, Hyderabad 3). Application of Sri/Smt Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal, Anantapur .Dt

<<<<<<<<<< 0>>>>>>>>>> I submit that the smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, Was under gone the treatment with Dentocare Super Speciality Hospital

CHADULLA, SINGANAMALA Mandal, Anantapur .Dt, Consultation.Root canal treatment,Ceramic crowns, at

Anantapur, from 10-10-09 to 20-10-09 and spent an amount of Rs 8660/- ( Rupees eight thousand six hundred and sixty only ) for the treatment and requested for Medical Reimbursement Hence I am here with submitting the Medical Reimbursement Proposals in respect of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal,

Anantapur .Dt with all fullfill requirements for payment I request you to sanction the Medical Reimburement to the individual as early possible Thanking you sir

yours faith fully Enclosers 1 2 3 4 5 6 7 8 Apendix -II Essentiality Certificate Non Drawl Certficate All Medical Bills Emergency Certificate Discharge Summary Check list Dependence Certificate

Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

FORM OF APPLICATION FOR MEDICAL CLAIMS

(MEDICAL REIMBURSEMENT) 1 2 3 4 5 Name of the Employee Designation and Basic pay Section and Office in which Employed Actual Residential Address with Door No Office and place where wife / husband is Employed Name of the Medical Attendent and address and Name of the Hospital with Regd No Name of the Patient and his / her relation ship to the Govt Servent ( In the case of children, state Age also) Nature of the Decease Period of treatment as in-patient as indicated in the certificates &Hospitalisation DR.M.Venkata Krishna Murthy Dentocare Super Speciality Hospital, Anantapur , smt resma wife of Y.Gangi Reddy S.G.T, Y.Gangi Reddy Basic pay Rs 7970/-

EDN SECTIOM MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal, Anantapur .Dt D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur

6 7

Sever Attrition,Badly decayed teeth ( copy enclosed )

From 10-10-09 to 20-10-09

10 Details of Medical Charges incurred

I
a)

MEDICAL ATTENDENCE
The Number and Dates of Consultaions and Fee paid for each consultaion The Number and Date of Injections and fess paid for injections Details of Laboratory Tests,X-rays ,and Scan etc 8660 Essentiality Certificates and Bills are Enclosed here with NO 1 Fee Rs 100

b)

c)

The Number and Dtae of Costs of d) Medicines(Details of the consolditated Medicines shall be furnished in the Essentiality Certificate)

II HOSPITAL TREATMENT
a) Accommmodation charges b) Pharmacy Charges c) Lab Charges (Details Shall be furnished) d) Surgeon's Fee e) Assist.Surgeon's Fee f) Anesthetic fee g) Theatre Charges h) Blood Charges i) Nursing Charges 11 Total Amount Claimed 12 Less Advance Received 13 Net Amount Claimed 14 No.Of Enclosures 8660 8660

Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

DECLARATION TO SIGNED BY THE GOVERNMENT EMPLOYEE

I here by declare that the statement in this application are true to the best of my knowledge and that The person for whom medical expenses were incurred is a member of my family as defined in API Medical Attendence Rules.He/She is dependent on me.Certified that my dependent is not a Govt.Employee.

SIGNATURE OF THE GOVT. EMPLOYEE/PENSIONER AND THE OFFICE TO WHICH HE IS ATTACHED

M.E.O M.P.SINGANAMALA

CHECK SLIP FOR SENDING MEDICAL REIMBURSEMENT PROPOSALS

S.NO Y.Gangi Reddy S.G.T MPUP SCHOOL CHADULLA SINGANAMALA M.P , Anantapur .Dt 2 3 4 5 6 7 8 Dates of Treatments Name and Address of the Hospital Whether Private or Government Whether the proposal is received in the head Office within a period of six months from the date of discharge ? Whether Appendix - II attested by the Head of the Office is enclosed ? In case of treatment at Recognised Hospital / NIMS / SVIMS whether Emergency certificate is enclosed ? Whether Essentiality certificate mentioning the amount of expenditure for the treatment, signed by the Doctor who treated and attested by the Authorised Medical Agency is enclosed ? Whether the Bills for the amount mentioned in the Essentiality certificate , signed by the Doctor , who treated and attested by the Authorised Medical Agency is enclosed ? Whether the Discharge summary of the patient is enclosed ? In case of retired Govt Employe / Teacher, whether the copy of the pension payment order is enclosed ? Incase of dependents above the age of 19 years unemployement and Dependency Certtificate,counter signed by the Head of Office is enclosed ? From 10-10-09 to 20-10-09 Dentocare Super Speciality Hospital, Anantapur Referal

Name and Official Address of the Teacher

10

11

12

Drawing and Disbursing Officer

Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

CHECK SLIP TO BE SIGNED AND FURNISHED BY THE GOVT.EMPLOYEES

(MEDICAL REIMBURSEMENT) Indicate 'YES' or 'NO' in the brackets against each item 1 All the columns of the Application form have been filled in properly The bill has been submitted along with Essentiality Certficate "A" for the treatment as out-patient by furnishing all the particulars and signed by the Medical Attendent who treated the patient The bill has been submitted along with Essentiality Certficate "B" for the treatment as Int-patient by furnishing all the particulars and signed by the Medical Attendent who treated the patient and counter signed by the Head of the Hospital The name of the disease has been indicated in the Essentiality certificate in Block letters The period of treatment has been indicated in the Essentiality certificate The case Doctor has signed on the Essentiality certificate and counter signed by the Head of the Hospital All the columns of theEssentiality certificates 'A' , 'B' have been filled in properly All the cash reciepts are with in the period of treatment The cash reciepts have been counter signed by the Doctor who treated the patient The name of the patient and the name of the Doctor has been indicated in all the cash receipts All the cash reciepts enclosed to the Medical reimbursement claim are dated The total amount of cash receipt tallied with the amount claimed The Duplicate bill with the copies of the original bills has been submitted

4 5 6 7 8 9 10 11 12 13

Sign of the Employee Drawing and Disbursing Officer

SRINIVAS

GANDHAMANEN I -

99594 22002

94402 69989

APPENDIX -II
(MEDICAL REIMBURSEMENT) APPLICATION FOR CLAIMING REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH MEDICAL ATTENDENCE AND / OR TREATMENT OF GOVERNMENT EMPLOYEE AND THEIR FAMILES 1 Name,Designation & Section Y.Gangi Reddy S.G.T EDN SECTIOM MPUP SCHOOL CHADULLA

Office in which Employed

PAY

SINGANAMALA M.P , Anantapur .Dt

DA HRA CCA IR O/A

Pay of the Govt.Servent as defined Which should be shown separately

7970

4805

797

80

1753

300

Rs 5750--13030 4 5 Place of Duty Full Residential Address with Door No Name of the Patient and his / her relation ship to the Govt Servent ( In the case of children, state Age also) Place at which the Patient fell ill Nature of the illness and its Duration MPUP SCHOOL, CHADULLA, SINGANAMALA , Anantapur .Dt D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur

6 7 8

smt

resma wife of

Y.Gangi Reddy

Residence From 10-10-09 to 20-10-09 ( copy enclosed )

Details of amount claimed ,cost of Rs 8660/Medicines purchased from the market / list of Medicines , Cash memos, and the Essentiality Certficate should be attached.Each in duplicate signed by Essentiality Certificates and Bills Enclosed here with treatment Doctor Total amount claimed 1 2 Rs 8660 Rupees Eight Thousand Six Hundred Sixty Only Hospital Reports 5 Emergency Certificate

10

Essentiality Certificate Discharge Summary 6 Non Drawl Certficate 7 Check list All Medical Bills 8 Dependence Certificate

11 List of enclosures

3 4

( All Originals in Duplicate Submitted )

DECLARATION TO SIGNED BY THE GOVERNMENT EMPLOYEE

I here by declare that the statement in this application are true to the best of my knowledge and that The person for whom medical expenses were incurred is a member of my family as defined in API Medical Attendence Rules.He/She is dependent on me.Certified that my dependent is not a Govt.Employee.

SIGNATURE OF THE GOVT. SERVENT/PENSIONER AND THE OFFICE TO WHICH HE IS ATTACHED M.E.O M.P.SINGANAMALA Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

APPENDIX -II
(MEDICAL REIMBURSEMENT)

REFUND OF MEDICAL EXPENSES INCURRED IN CONNECTION WITH OR TREATMENT OF GOVERNMENT EMPLOYEE AND THEIR FAMILES Y.Gangi Reddy S.G.T EDN SECTIOM MPUP SCHOOL CHADULLA

SINGANAMALA M.P , Anantapur .Dt

TOTAL

15705 Rs 5750--13030 MPUP SCHOOL, CHADULLA, SINGANAMALA , Anantapur .Dt D.No.12/153,Cental Excise Colony,Sai Nagar,Anantapur

smt

resma wife of

Y.Gangi Reddy

Residence From 10-10-09 to 20-10-09 ( copy enclosed ) Rs 8660/-

Essentiality Certificates and Bills Enclosed here with

Rupees Eight Thousand Six Hundred Sixty Only Emergency Certificate Discharge Summary

Dependence Certificate

( All Originals in Duplicate Submitted )

TO SIGNED BY THE GOVERNMENT EMPLOYEE

atement in this application are true to the best of my knowledge and that The

es were incurred is a member of my family as defined in API Medical

dent on me.Certified that my dependent is not a Govt.Employee.

SIGNATURE OF THE GOVT. SERVENT/PENSIONER AND THE OFFICE TO WHICH HE IS ATTACHED

NON - DRAWL CERTFICATE

This is to certify that the amount of Rs 8660/-.( Rupees eight thousand six hundred and sixty only ) has not been paid previously ,towards medical reimbursement in respect of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal, Anantapur .Dt ,on his/her treatment taken during the period from 10-10-09 to 20-10-09 for the Disease

Consultation.Root canal treatment,Ceramic crowns, in the hospital

Dentocare Super Speciality

Hospital Anantapur, and this is the first Spell for the disease and entered in the Medical Reimbursement Register

Signature of the drawing and disbursing officer Signature of the applicant.

DEPENDENT CERTIFICATE

I, Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Mandal, Anantapur .Dt hereby declare that smt , resma has no property of income of his/her own and that

he/she is wholly dependent on me. He/she is also not a employee or pensioner.

Signature of the applicant.

Signature of the forwarding officer

SRINIVAS

GANDHAMANENI -

99594 22002

94402 69989

APTC FORM - 58
FULLY VOUCHRED CONTINGENT BILL

Payble at

For the Month & Year District:

D.D,O`s T.B.R.No

12

2009

DIST TREASURY OFFICE DTO (PLANED)

Anantapur

For Treasury use Only Date:Trans ID:-

TREASURY / PAOCODE DDO Code:

Major Head

2 0

2 1

2 Education
Ele..Edn.

General

1003567-0092

Sub - Major Head

DDO Designation:

M.E.O
M.P.P

Minor Head

Asst. to local Bodies ,

DDO, Office Name. M.P.SINGANAMALA Group Sub - Head

Bank Branch Code Bank Branch Name:

80
SBI B.K.SAMUDRAM

Sub - Head Detailed Head

0 0

5 1 0

Teaching grant to M.PS. Salaries

Sub - Detailled Head

Medical reimbursment 0

Non-Plan = N/ Plan =P

Charged = C/ Voted = V: Deduction Rs : -

Contingency Fund MH/ Service Major Head

Gross Rs :-

8660

Net Rs:_

8660

F tv hn || qv h l VwAVAf. pOdml

8660

eight thousand six hundred and sixty only

.F mSl / VO / fp / PhY / sd

f V ClO f V ClO
FOR USE IN TREASURY / PAY & ACCOUNTS OFFICE ONLY Pay Rs ..... (Rupees.. . Only) by Cash / Cheque / Draft / Account Credit as under and Rs . (Rupees . Only) by adjustment. 1. Rs by transfer credit to the S.B. Accounts of the employee (As per Annexure - 1) 2. Rs by trancefer credit to the D.D.O. Account towards non - government deducations.

NBST / Bank Seal

Treasury Officer / Pay & Accounts Officer Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

TC FORM - 58

Payble at DIST TREASURY OFFICE (PLANED)

For Treasury use Only

General Education Ele..Edn.

Asst. to local Bodies ,

Teaching grant to M.PS. Salaries

Medical reimbursment

8660
)

mSl / VO / fp / PhY / sd

PARTICULARS OF AMOUNT CLAIMED IN THIS BILL

No.& Description of Sub - Voucher

Details of expenditure and authority for sanction, drawal of amount

/2008

Medical reimbursment bill of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Anantapur .Dt as per Prog R.C.No.5601/B5/2007 , dated 00-01-00 of the DIST.EDUCATIONAL OFFICER, ANANTAPUR.

Total
( eight thousand six hundred and sixty only

Non - Drawel Certificate

This is to certify that the amount climed in this bill was not drawn and paid previously

Total Amount Rs : (

eight thousand six hundred and sixty only

sfd v
1. 2008 AhnO sfd OdAp : 2. Ftvh Cm A : 3. nv 1.Budget provided for the year 2.Expenditure including this bill 3.Balance :

COAdAd Ymv Ov GpSA

Srinvas Gandhamaneni - 99594 22002 * 9440269989 "www.apteachers.blogspot.com"

OF AMOUNT CLAIMED IN THIS BILL

Amount

8660.00 8660.00 )

mount climed in this bill was not drawn and paid previously

8660.00 )

f V ClO

sfd v

f V ClO

mv Ov GpSA

9594 22002 * 9440269989 "www.apteachers.blogspot.com"

ANNEXURE-I
(Notifide Pay Bank) (Employee Wise Details)

Name of the NPB: D.D.O.Code : D.D.O.Designation:

SBI ,

B.K.SAMUDRAM

NPB Code : Date : Trance-ID:

Employee SBI A/C No

80 12/12/2009

1003567-0092
M.E.O

M.P.SINGANAMALA
S.No Employee Code Name of the Teacher

Amount

11111234567

Y.Gangi Reddy

123456789023

8660.00

TOTAL ( eight thousand six hundred and sixty only )

8660

M.E.O M.P.SINGANAMALA

Assistant Treasury Oficer ANANTAPUR

ANNEXURE-II
(Notifide Pay Bank) (Employee Wise Details)

Name of the NPB: D.D.O.Code : D.D.O.Designation:

SBI ,

B.K.SAMUDRAM

NPB Code : Date : Trance-ID:

80 12/12/2009

1003567-0092 M.E.O M.P.SINGANAMALA

0 Amount to be credited

S.No

Name of the NPB

Purpose

SBI ,

Medical reimbursment bill of smt resma w/o, B.K.SAMUDRAM Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA , Anantapur .Dt.

8660

TOTAL ( eight thousand six hundred and sixty only )

8660

M.E.O M.P.SINGANAMALA

Assistant Treasury Oficer ANANTAPUR

ANNEXURE - III GOVT.BANK REPORT TO BE GENERATED BY TREASURY OFFICE

Treasury Code:

80

Treasury Office Name : DTO ,ANANTAPUR

Govt. Bank Code:

80 Name & Code of NLB

Govt, Bank Name:

SBI ,B.K.SAMUDRAM Amount to be Credited

S.No

DDO Account Number

Purpose Medical reimbursment bill of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Anantapur .Dt.

123456

8,660

Total

8,660

eight thousand six hundred and sixty only

Signature of the Bank Officer (With Seal)

Signature of the Treasury Officer (With Seal)

ANNEXURE - III GOVT.BANK REPORT TO BE GENERATED BY TREASURY OFFICE

Treasury Code: Govt. Bank Code:

80

Treasury Office Name : Govt, Bank Name:

DTO ,ANANTAPUR SBI ,B.K.SAMUDRAM

80 Name & Code of NLB

S.No

DDO Account Number

Purpose

Amount to be Credited

123456

Medical reimbursment bill of smt resma w/o Sri Y.Gangi Reddy, S.G.T, MPUP SCHOOL, CHADULLA, SINGANAMALA Anantapur .Dt.

8660

Total

8660

eight thousand six hundred and sixty only

Signature of the Bank Officer (With Seal)

Signature of the Treasury Officer (With Seal)

ANDHRA PRADESH GOVERNMENT

(PAPER TOKEN)
STO Code: DTO/STO Name: DDO Code: 1 0 0 1 Date : Trans ID: M.P.P M.P.SINGANAMALA SBI B.K.SAMUDRAM
(For Treasury Use Only)

Anantapur

1003567-0092

DDO Designation :

M.E.O

DDO Office Name:

Bank Branch Code:

80

BANK Name:

Head of Account

3 (Grp - SH) 0 1

(Major Head) 0 5

(Sub - MH) 0 1 0

(Major Head)

(Sub Head)
Non - Plan = N Plan =P:
Charged = C Voted = V:

(Det. Head)
Contingency Fund MH/Service Major Head

(Sub - Det. Head)

Gross Rs.

8660.00 Deducation Rs.

Nill

Net Rs.

8660.00

eight thousand six hundred and sixty only

Messenger Name (As in APTC From (101) Specimen Signature of Messenge 1.

Designation

DDO Signature

Attested

STO Signature

DDO Signature DDO Seal TreasuryS eal

PRADESH GOVERNMENT
(PAPER TOKEN)
(For Treasury Use Only)

M.P.P M.P.SINGANAMALA SBI B.K.SAMUDRAM

(Grp - SH) 7 (Sub - Det. Head)

8660.00

APTC FORM 101

(See Subsidiary Rull 2 (W) Under Treasury Rule 15 Govt. Memo No :38907 / Accounts / 65-5, Dt 21.02.1993)

DDO Code DDO Designation

1003567-0092
M.E.O

Treasury/PAO Code Treasury/PAO Name:

DTO ,ANANTAPUR

To
The Treasury Officer/Manager SBI B.K.SAMUDRAM

Please Pay Bill No

dated eight thousand six hundred and sixty only

for Rs

8660

to Smt/ Sri whose specimen Signature is attensted herewith.

Signature of the Govt. Servant Dated :

Received the payment Dated

Attested

Signature of the D D O D D O Seal

Signature of the Govt. Servant receiving the Payment

ESSENTIALITY CERTIFICATE
CERTIFICATE "A" (To be completed in the case of patients who are not admitted to Hospital for treatment) #REF!

I , DR.M.Venkata Krishna Murthy here by certifiy :a) That I charged and received Rs b) That I charged and received Rs 100 for consulting at my room/at patient residence for administering at my

Intra venous/mascular /sub-cutaneous Injection on consulting room/at patient residence c) That the injections administered was/were not for immunizing or prophylactic purpose

d) That the patient has been under treatment at Dentocare Super Speciality Hospital / my consulting room, and that the undermentioned medicines prescribed by me in thes connection were essential for the recovery / prevention of serious deterioration in the condition of the patient.The medicines are not stocked in Dentocare Super Speciality Hospital for the supply to private patients and do not include proprietary preparations for which cheaper substances of therapeutic value are available not preparations which are primerily foods,toilets or disinfectants Name of medicines Price

e) That the patient is/was suffering from and is /was under treatment from ########

Sever Attrition,Badly decayed teeth

to ########

f) That the patient is/was not given pre-natal or post- natal treatment g) That the X-ray / Laboratory tests / treatment etc.. For which an expenditure of Rs 8660/-( Rupees eight thousand six hundred and sixty only ) was incurred were necessary and were undertaken on my advice at Dentocare Super Speciality Hospital Anantapur h) That I refered the patient to Dr and that necessary approval of the (Name of the Chief Admin.Medical Officer of the State as required under the rules was obtained) i) That the patient did not require Hospitalization j) That the mixture / ointment /powder entered at serial ( ) undet Certificate (d) could not be dispensed at the Hospital and the patient was advised to buy it from the market for specialist consultation

Date:-

Sign of the AMA/Designtion of the Medical Officer, and Hospital / Dispensary to which attached

Note:-

Certificates not applicable should be struck off.certficate (e) is compulsory and must be filled in by the Medical officer in all cases

GOVT. OF ANDHRA PRADESH (APTC Form - 47)

Payable at D.T.O, Anantapur Pay Bill for the Month & Year D.D.O., Anantapur D.D.O. Code D.D.O.Designation Bank Code D.D.O.' s TBR No:-. Head of Account Major Head Sub Major Minor Head Group Sub-Head Sub Head Detailed Head
Teaching Grants to M.Ps Salaries General Education Elementary Education Assistance to Local

09 1001

2009
Date :Trans ID :

(For Treasury Use Only) 12/12/2009 345

1001-0308-014 District :
HEADMASTER DDO Office Name : GHS NO.1 Anantapur

ANANTAPUR Mandal Parishad Anantapur Rural SBI,ANANTAPUR

0250

Bank Name : Permanet / Temporary:Deductions

bodies on primery Edn

Non-plan=N/Plan=P Contingency Fund MH/ Service Major HeadPay 011 012 013 015 016

Charged=C/V Voted=V :

Allowances Dearness Allowance HRA CCA IR Gross Amount Less Amount AG Net Amount

Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.

3662.00 1066.00 493.00 12.00 0.00 5233.00

1 GPF/AIS/PF 2 APGLI 3 Group Insurance/AIS 4 Professional Tax 5 House Rent 6 Festival Advance 7 Apco Advance 8 Education Advance 9 H.B.A. (P) 10 H.B.A. (I) 11 Car Advance (P) 12 Car Advance (I) 13 Motor Cycle Advance (P) 14 Motor Cycle Advance (I) 15 Cycle Advance 16 Marriage Advance (P) 17 Marriage Advance (I) 18 Income Tax 19 Class IV GPF-DTO 20 E.W.F. 21 ZPPF (8338) 22 Total Govt. Deductions

Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs

5233.00 Total Non-Govt. Deduction 0.00 Total Deductions

AG Net Amount in words

D.D.O's Signature FOR USE IN TREASURY / PAY & ACCOUNTS OFFICE ONLY

Pay Rs. ....... (Rupees ..

.....only) by Cash / Cheque / Draft / Account Credit as under and Rs.

(Rupees ..only) by adjustmen 1 Rs. . ..By transfer credit to the S.B. Accounts of the employees (As per Annexure - I).
NBST / Bank Seal

2 Rs. .. by transfer credit to the D.D.O. Account towards non-government deductions.

Treasury Officer / Pay & Accounts Officer SRINIVAS GANDHAMANEN I 99594 22002 94402 69989

VT. OF ANDHRA PRADESH (APTC Form - 47)

Payable at D.T.O, Anantapur (For Treasury Use Only) 12/12/2009 345 ANANTAPUR Mandal Parishad Anantapur Rural SBI,ANANTAPUR

Deductions Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs. Rs.

5233.00
Rs.

5233.00
Rs.

5233.00

D.D.O's Signature IN TREASURY / PAY & ACCOUNTS OFFICE ONLY

pees ...

ash / Cheque / Draft / Account Credit as under and Rs. .

only) by adjustment.

. ..By transfer credit to the S.B. Accounts he employees (As per Annexure - I).

.. by transfer credit to the D.D.O. ount towards non-government deductions.

BUDGET DETAILS

1. BUDGET ALLOTMENT FOR THE YEAR 2. EXPENDITURE INCLUDING THIS BILL 3. BALANCE

Rs. Rs. Rs.

DDO The bill amount Rs ( 5833

Received Amount Rs

DDO DDO

Required Certificates
1 2 3 4 5 6 7 8 9 10 11 12 Certified that the Amount was not drawn paid previously. Certified that the Pay Amount was calaimed G.O.MS.No. 180 Dated 29-6-06 Certified that the D.A. Amount was Claimed G.O.MS NO 139.Dated 5-6-08 Certified that the D.A. Amount was Claimed G.O.MS NO 19,Dated :-2-2-07 Certified that the D.A. Amount was Claimed G.O.MS NO :-133,Dated:-12-06-07 Certified that H.R.A. Amount was Claimed G.O.MS.No.181,Dated 29/06/2006 Certified That C.C.A Amount was Claimed G.O.MS.No.182,Dated 29/06/2006 Certified That I/R Amount was Claimed G.O.MS.No.303,,Dated 15/10/08 Certified that the Pay Amount was calaimed G.O.(P).No. 241 Dated 28-09-2005 G.O.M.SNo.54 Education ( SE-SER-III) Departmrnt dated 02-08-07. G.O.M.SNo.38 Education ( SE-SER-III) Departmrnt dated 26-05-07. Certified that necessary entries were made in the individual S.R

DDO

FOR USE IN ACCOUNTANT GENERAL OFFICE

SRINIVAS

GANDHAMANEN I -

99594 22002

94402 69989

BUDGET DETAILS

Required Certificates

DDO

USE IN ACCOUNTANT GENERAL OFFICE