START UP FARMS IT PRIVATE LIMITED

CHANDIGARH
MEDICAL EXPENSE CLAIM FORM
Name
ABHIHEK AGNIHOTRI
Ecode
E097
Division
DEVELOPMENT
Designation:
MANAGER
Pls allow reimbursement of medical expenses incurred as per details below:
Expense for
Name of the Doctor/Chemist
Self/Dependant
Bill No.
bhargav medical store
Mother
5239
pankaj garg/ bhargav medical store
Wife
5620
Aman Choudhary/ Bhargav Medical
Arpita Garg/mahaveer medicose

Daughter
Wife

Date
9-Jan-15
9-Jan-15

Amount
87
314

5614
2651

9-Jan-15
3-Feb-15

98
228.5

Rishab Bansal/bansal medicose

Rishab bansal/bansal medicose
Rishab bansal/Shakti medical

Mother
Father
Mother

2911
2912
64707

16-Jan-15
16-Jan-15
29-Dec-14

1852
285
240

Rishab bansal/bansal medicose

Rishab bansal/bansal medicose

Mother
Mother

2469
2455

23-Nov-14
21-Nov-14

687
459

Mother
Self

2287
16188

2-Nov-14
17-Aug-14

543
1972

Rishab bansal/bansal medicose

Vivek Malhotra/G.D. Medicose

Rupees in Words :

TOTAL
Sixty seven hundred sixty five rupess only

Declaration :
I hereby declare that the particulars furnished are true to the best of my knowledge and belief and also
undertake that in case the above reimbursement claim is found to be inappropriate, I undertake to refund
the said claimed amount & also liable for payment of income tax rebate claimed/penalty on this account.

Date :

All bills are to be submitted in original.

Signature of Claimant

6765.5

START UP FARMS IT PRIVATE LIMITED

CHANDIGARH
TELEPHONE EXPENSE CLAIM FORM
Name
Ecode
Division
Designation:
Particulars

ABHISHEK AGNIHOTRI
E097
Alert/STI/SUFI
MANAGER
Telephone/
Month
Amount INR
Mobile Number
APRIL
9467809143
MAY
9467809143
JUNE
9467809143
JULY
9467809143
AUGUST
9467809143
SEPT
9467809143
OCTOBER
9467809143
NOVEMBER
9467809143
DECEMBER
JANUARY
FEBURARY

TOTAL
Rupees in Words :

9467809143
9467809143
9467809143

572
589
439
277
251
232
466
435
558
385
593
4797

Fourty seven hundred ninety seven rupees only

Declaration :
I hereby declare that the particulars furnished are true to the best of my knowledge and belief and also
undertake that in case the above reimbursement claim is found to be inappropriate, I undertake to refund
the said claimed amount & also liable for payment of income tax rebate claimed/penalty on this account.

Date :

Signature of Claimant

START UP FARMS IT PRIVATE LIMITED

CHANDIGARH
Vehicle Running and Maintenance Expenses Claim Form
Name
Ecode
Division
Alert/STI/SUFI
Designation:
Pls allow reimbursement of Vehicle running and maintenance expenses incurred as per details below:
Particulars of Invoices

Fuel/Maintenance

Bill No.

Date

Amount

TOTAL
Rupees in Words :
Declaration :
I hereby declare that the particulars furnished are true to the best of my knowledge and belief and also
undertake that in case the above reimbursement claim is found to be inappropriate, I undertake to refund
the said claimed amount & also liable for payment of income tax rebate claimed/penalty on this account.

Date :

All bills are to be submitted in original.

Signature of Claimant

START UP FARMS INDIA PRIVATE LIMITED

CHANDIGARH
LTA REIMBURSEMENT CLAIM FORM
EMP Name: Mr./Ms.
Designation:
Date of Joining :

No. of members
accompanied :
Name
From

To

Relation

No. of Days

Period of Leave
Claim of Expenses :
Travel Dates
From

Place of Visit
To

From

To

Mode / Name
of Transportation

Amount

TOTAL
Rupees in Words :
Declaration :
I hereby declare that the particulars furnished are true to the best of my knowledge and belief and also
undertake that in case the above reimbursement claim is found to be inappropriate, I undertake to refund
the said claimed amount & also liable for payment of income tax rebate claimed/penalty on this account.

Date :

Signature of Claimant

FOR HR DEPTT. / FINANCE DEPTT.

No. of Days leave marked
From

HR Deptt.

LTA claim Amount

To

LTA passed for

Accounts Deptt.