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Annexure-2 to OM No. C1173/675 of 20 June, 1975\\
%of 20 June, 1975
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FORM
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\begin{enumerate}
\item 
Date of last claim
\item
Period for which reimbursement was claimed
\item
Period to which present claim pertains
\end{enumerate}

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 \hline\\
Name of child 
& 
School in which studying and location of the school (state also whether it
is a Govt.\ or a Govt.\ aided school)
&
Class in which studying
&
Monthly tuition fees paid actually
&
Amount of Govt.\ scholarships, if any
&
Amount of scholarship received from other
sources (N.B. Merit scholarships specifically
marked for item other than tuition fees need not to be
mentioned)
&
Amount of reimbursement claimed (to be restricted to
fees approved by educational authorities)
\\
\hline
\\
(1) &(2)&(3)&(4)& (5)&(6)& (7)\\
\hline 
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\begin{enumerate}
\item 
Certified that my child/children mentioned above in respect of whom
reimbursement of tuition fees is claimed is/are studying in the school(s)
mentioned in column (2) which is/are recognised school and that the tuition fees
indicated against each have actually been paid by me.
  
\item
Certified that:
\begin{enumerate}
\item 
My wife/husband is not in Institute service.
\item 
My wife/husband is in Institute service and that reimbursement would be 
claimed by her/him and also the pay drawn by her/him does not exceed
Rs.\ 1200/- per month.
\item 
My wife/husband is employed with \makebox[10em]{\dotfill}. She/he is not entitled to
and availing of reimbursement of fees for  our children.
\end{enumerate}

\item
Certified that the name of the children mentioned above has been studying
in the same class for more than two years.

\item
Certified that I have not claimed and will not claim the Children's Educational Allowances
in respect of the children mentioned above (Strike out if not applicable).

\end{enumerate}

\begin{itemize}
\item 
Strike off what is not applicable.
\item 
Employer other than Indian Statistical Institute to be mentioned.
\end{itemize}

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Signature and Roll No.\ of \\one Institute employee
 
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