8/12/2019 FormNo Gen20

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Indian InstitutIndian InstitutIndian InstitutIndian Institute of Technologye of Technologye of Technologye of Technology GuwahatiGuwahatiGuwahatiGuwahatiA C A D E M I C S E C T I O N

Form No. GenGenGenGen////20202020 Contingency Expenses Reimbursement FormContingency Expenses Reimbursement FormContingency Expenses Reimbursement FormContingency Expenses Reimbursement Form

1. Contingency A/c Code of the concerned academic Dept./Centre:_________________________________

2. Name of Claimant (in BLOCK letter): _______________________________________________________________

3.

Programme (Please tick []]]]): M. Tech / M. Des / Ph. D /M. Tech / M. Des / Ph. D /M. Tech / M. Des / Ph. D /M. Tech / M. Des / Ph. D / Dual (M. Tech + Ph. D)Dual (M. Tech + Ph. D)Dual (M. Tech + Ph. D)Dual (M. Tech + Ph. D)

4. Roll No.: _______________________________________________________________________________________

5.

Department / Centre: ____________________________________________________________________________

6.

Session: ________________________________________________________________________________________

7.

Contact Phone No.: ______________________________________________________________________________

8. email: __________________________________________________________________________________________

9. Amount of reimbursement (Maximum Rs.5,000/- per annum):________________________________________

10.Bank A/c No. of the claimant: _____________________________________________________________________

11.

Name and Branch of Bank: ________________________________________________________________________

DETAILSDETAILSDETAILSDETAILS OF EXPENDITUREOF EXPENDITUREOF EXPENDITUREOF EXPENDITURE****

Sl. No.Sl. No.Sl. No.Sl. No.Description of ItemsDescription of ItemsDescription of ItemsDescription of Items (Voucher(Voucher(Voucher(Voucher

No.)No.)No.)No.)

VVVVoucheroucheroucheroucher

DateDateDateDate

Qty.Qty.Qty.Qty. RateRateRateRate Total AmountTotal AmountTotal AmountTotal Amount

1.2.

3.

4.5.6.7.

8.9.10.

Total ExpenditureTotal ExpenditureTotal ExpenditureTotal Expenditure

Note: * To be submitted on one-time basis only latest by the month of February for a financial year.

(Rupees _______________________________________________________________________________________________ only)

Signature of ClaimanSignature of ClaimanSignature of ClaimanSignature of ClaimanCertified that the reimbursement claim has been done on oneon oneon oneon one----time basistime basistime basistime basis for financial year

Recommended / Not-Recommended

HOD / HHOD / HHOD / HHOD / HAAAACCCC

[Vouchers[Vouchers[Vouchers[Vouchers / Bills / Cash Memo/ Bills / Cash Memo/ Bills / Cash Memo/ Bills / Cash Memos are to be attached chronologically with self attestation by thes are to be attached chronologically with self attestation by thes are to be attached chronologically with self attestation by thes are to be attached chronologically with self attestation by the ClaimantClaimantClaimantClaimant]]]]

For Office use only (ACADEMICFor Office use only (ACADEMICFor Office use only (ACADEMICFor Office use only (ACADEMIC SECTIONSECTIONSECTIONSECTION))))::::

12.Whether the above referred person is a MHRD funded registered Regular M.Tech./M.Des/Ph.D./Dual (M.Tech +

Ph.D) student or not? [Yes/No] . If No, the status is

Dealing AssistantDealing AssistantDealing AssistantDealing Assistant DR/AR(Acad.)DR/AR(Acad.)DR/AR(Acad.)DR/AR(Acad.) DOAA/ADOAADOAA/ADOAADOAA/ADOAADOAA/ADOAA

For Office use only (For Office use only (For Office use only (For Office use only (FINANCE & ACCOUNTS SECTIONFINANCE & ACCOUNTS SECTIONFINANCE & ACCOUNTS SECTIONFINANCE & ACCOUNTS SECTION))))::::

Checked and passed for payment of `_____________________________ (Rupees _________________________________________________________________ only) towards the claim.

Dealing AssistantDealing AssistantDealing AssistantDealing Assistant Accounts Officer (F&A) Accounts Officer (F&A) Accounts Officer (F&A) Accounts Officer (F&A) AR /AR /AR /AR / DR (F&A)DR (F&A)DR (F&A)DR (F&A)

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