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{\Large{\bf Indian Statistical Institute}}\\
{\large{\bf Delhi Centre}}\\
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FORM-2
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{\large{\bf Reimbursement of Children Education Allowance}}\\
$\left [\mbox{Ref: OM No. 12011/03/2008 (Allowance) dated 02/08/2008}\right ]$
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\begin{center}
\begin{enumerate}
 \item Certified that the children/child mentioned below in respect of whom reimbursement of children Education Allowance claimed is wholly dependent upon me:-
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\begin{tabular}{|c|c|c|c|c|} \hline 
\multicolumn{1}{|c|}{\bf Name of the Child \&}  & \multicolumn{1}{|c|}{\bf School in} & \multicolumn{1}{|c|}{\bf Class in which} & \multicolumn{1}{|c|}{\bf Total} & \multicolumn{1}{|c|}{\bf Total Amount of} \\
\multicolumn{1}{|c|}{\bf Date of birth} & \multicolumn{1}{|c|}{\bf  which  } & \multicolumn{1}{|c|}{\bf studying \& A/Y} & \multicolumn{1}{|c|}{\bf Education} & \multicolumn{1}{|c|}{\bf reimbursement } \\
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf studying  } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf allowance} & \multicolumn{1}{|c|}{\bf claimed} \\
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf paid} & \multicolumn{1}{|c|}{\bf } \\ \hline 


\multicolumn{1}{|c|}{\bf \hspace*{0.7in} (1) \hspace*{0.7in} } & \multicolumn{1}{|c|}{\bf \hspace*{0.5in}  (2) \hspace*{0.5in} } & \multicolumn{1}{|c|}{\bf (3) } & \multicolumn{1}{|c|}{\bf (4)} & \multicolumn{1}{|c|}{\bf  (5)} \\ \hline 

\multicolumn{1}{|l|}{\bf 1) } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ 
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ 
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ 
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ \hline 


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{4}{|l|}{\bf  \# Tuition fees- for the Whole Year 200\qquad- \qquad/I/II/III/IV - Term} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of books } & \multicolumn{2}{l}{\bf   (One set/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of Note books } & \multicolumn{2}{l}{\bf   (One set/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of Uniforms} & \multicolumn{2}{l}{\bf   (Two sets/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of School Shoes } & \multicolumn{2}{l}{\bf   (One set/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline
%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{4}{|r|}{\bf  To be filled in Column 4 above } & \multicolumn{1}{|l|}{\bf Rs.  } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  2)} & \multicolumn{1}{|l|}{\bf   } \\
%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline

\multicolumn{1}{|l|}{\bf 2) } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ 
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ 
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ 
\multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } & \multicolumn{1}{|c|}{\bf } \\ \hline 



%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{4}{|l|}{\bf  \# Tuition fees- for the Whole Year 200\qquad- \qquad/I/II/III/IV - Term} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of books } & \multicolumn{2}{l}{\bf   (One set/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of Note books } & \multicolumn{2}{l}{\bf   (One set/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of Uniforms} & \multicolumn{2}{l}{\bf   (Two sets/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline


%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{2}{|l}{\bf  Purchase of School Shoes } & \multicolumn{2}{l}{\bf   (One set/per child/per AY/)} & \multicolumn{1}{|l|}{\bf  Rs. } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ 
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline
%\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\
\multicolumn{4}{|r|}{\bf  To be filled in Column 4 above } & \multicolumn{1}{|l|}{\bf Rs.  } \\
\multicolumn{4}{|l|}{\bf  } & \multicolumn{1}{|l|}{\bf   } \\ \hline
\end{tabular}

\newpage
\item Certified that the Education Allowance indicated against the Child/Children has actually been paid by me (Receipts enclosed)\\
{\bf (Note : Copy of School fee card \& Bank Challans/Paid up Receipts/purchase receipts in Original are to be enclosed)}

\item Certified that : 
\begin{itemize}
\item [i)] My spouse is not a Central Government servant.\\
\item [ii)] My spouse is a Central Govt. servant and that she/he has not claimed/will not claim children's educational allowance in respect of our child/children.
\end{itemize}
\item Certified that during the period covered by the claim the child attended the school regularly and did not absent himself/herself from the school without proper leave for a period exceeding one month.

\item In the event of any change in the particulars given above which affect my eligibility for children's educational allowance, I undertake to intimate the same promptly and also to refund excess payments, if any made.

\item[{\bf Note :}] \# Tuition Fee Means Tuition fee, Admission fee, lab fee, special fee charged for agriculture, electronics, music or any other subject, fee charged for practical work under the programme of work experience, fee paid for the use of any aid or appliance by the child, library fee, games/sports fee and fee for extra curricular activities.
\end{enumerate}
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\noindent Encl. \hfill{(Signature of Workers)}
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\noindent Place \& Date :
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\multicolumn{1}{|c|}{\bf  } & \multicolumn{1}{|c|}{\bf  } \\