Annexure ‘A’

PERFORMA FOR RE-IMBURSEMENT OF CHILDREN EDUCATION

ALLOWANCE/ HOSTEL SUBSIDY FOR THE ACADEMIC YEAR: ______________
I, hereby apply for the reimbursement of Children Education Allowance for my
child/children and relevant particulars are furnished below:

FIX PHOTO OF FIX PHOTO OF FIX PHOTO OF

EMPLOYEE FIRST CHILD SECOND CHILD

1 Name of Employee :
2 CPIS Number :
3 Designation :
4 Present Department/Office :
5 Name of Spouse :
If spouse is employed, state whether in :
6 Central Govt., PSU, State Govt. (give
details)
7 Name, Designation and Office address of :
the Spouse.

8 Detail of the children for whom CEA/Hostel Subsidy claimed:

S. No. Sequence Name DOB Age
st
1 1 Child
2 2nd Child

9 Name of School/residential School and Class in which children studied:

1st Child 2nd Child

10 Distance of Hostel of child from residence of employee (in case Hostel Subsidy
is claimed) __________________.
11 The Academic year for which CEA/Hostel Subsidy is applied now: __________________
12 (a) Whether the child for whom the CEA is applied for is a disabled child: YES /NO
(b) If yes, indicate the nature of disability:
(c) Date of disability certificate.
(d) Indicate the percentage of disability:
13 Whether the Bonafied certificate from Head of Institution has been attached: YES/NO
14 For Hostel Subsidy, the Bonafied certificate from mentioning the amount is
attached: YES/NO.
15 If Yes at Item No. 14, Amount claimed for Hostel Subsidy__________________
16 (i) Certified that the fee / amount indicates above had actually been paid my me.
(ii) Certified that my wife / husband is / is not a Central/State Govt. Servant.
(iii) Certified that my husband / wife Sri/Smt. ________________________ is presently
working as: ______________________________ in ________________________ and
that he/she shall not apply/has not applied for the Children Education Allowance for the
children mentioned above.
(iv) Certified that I or my husband/wife has not claimed this reimbursement from any
other source and will not claim the same in future.
17 Certified that my child in respect of whom reimbursement of Children Education
Allowance is applied is studying in the School/ Jr. College which is recognized and affiliated
to Board of Education/University.
18 The information furnished above are complete and correct and I have not suppressed any
relevant information. In the event of any change in the particulars given above which
affect my eligibility for reimbursement of Children Education Allowance. I undertake to
intimate the same promptly and also to refund excess payments if any made. Further, I
am aware that if at any stage the information/documents furnished above is found to be
false, I am liable for disciplinary action.

Signature_________________
Name______________________
Desgn______________________
Date_____________________
The details of child/children for whom the present claim is submitted by the official has been
verified from the official records and found correct.

Signature of Administrative Authority

with office stamp
 Annexure ‘B’

BONAFIDE CERTIFICATE FROM THE HEAD OF INSTITUTION/SCHOOL

This is to certify that Master/Baby/Mr./Mrs.______________________________ Son/

Daughter of Sri/Smt.____________________________Roll no.________________ Admission
No_________ is a bonafied student of this school and studied in Class_______ during the
academic year_____________ and as per School records his/her date of birth is
_____________________________________________________

**This is further certified that during the year Master/Baby/ Mr./Miss

___________________________________ had resided in the residential complex (hostel) of the
school and paid an amount of Rs_________________ towards boarding and lodging in the
residential complex.

This Institution/School is affiliated to/ recognized by _______________________ vide

affiliation/ recognition Number_______________________.

Dated:
Place: Signature Head of the
Institution/School
(with Stamp and seal)

**(Strike out it if not applicable)

 Annexure “C”
NOMINATION FORM FOR AVAILING CHILDREN EDUCATION ALLOWANCE

SELF DECLARATION

I____________________________________ do hereby certify that my Son/Daughter namely

1.___________________________________________________________________ studied in
class__________Sec._______Rollno.______,School Name _____________________________

2.___________________________________________________________________ studied in
class__________Sec._______Rollno.______,School Name _____________________________
during previous Academic Year ______________

I also certify that my spouse

is not a Govt. Employee

is a Govt. Employee and NOC is enclosed.

In the event of any change in the particular given above which affect my eligibility for
Children Education Allowance. I undertake to intimate the same promptly and refund excess
payment, if any to me.

Signature of Govt. Servant

Name ________________
Desg_________________
 FORM 3
[See rule 54 (12)]
Details of Family

1. Name of the Government servant__________________________________

2. Designation______________________
3. Date of birth______________________
4. Details of the members of family as on________________:

S. No Names of the Date of Relationship Marital Remarks Dated

members of family Birth with the status signature of
officer Head of Office

(1) (2) (3) (4) (5) (6) (7)

1.
2.
3.
4.
5.
6.
7.

I hereby undertake to keep the above particulars up-to-date by notifying to the Head of
the Office any addition or alteration.

Signature of Government servant

Place :
Date :
Note 1. – The original Form submitted by the Government. servant is to be retained. All
additions/alterations are to be recorded in this Form under the signature of Head of Office in
Column no. 7. No new Form will substitute the original Form. However, the retiring
Government servant should submit the details of family afresh along with Form 5.
Note 2. – The details of spouse, all children and parents (whether eligible for family pension
or not) and disabled siblings (brothers and sisters) may be given.
Note 3. – The Head of Office shall indicate the date of receipt of communication regarding
addition or alteration in the family in the ‘Remarks’ column. The fact regarding disability or
change of marital status of a family member should also be indicated in the ‘Remarks’ column.

Note 4. - Wife and husband shall include judicially separated wife and husband.