CLAIM FORM FOR POCKET MONEY TO EX-SERVICEMEN SUFFERING FROM TUBERCULOSIS, LEPROSY OR CANCER FROM THE TAMIL NADU EX-SERVICES PERSONNEL BENEVOLENT FUND Month and Year for which the claim is made : Name of the sanatorium/ Leprosium/ Government Hospital : Pocket Money Claim at Rs. .... per day as under :- Sl.No. Regtl. No. Rank, Name Date ofAmount claimed and unit in which admission ----- served ---------- --------------- --------------- ------------- Days-------- ------ Amount ----------------------------- (1) (2) (3) (4) (5) (6) Total Certified (1) All the patients listed above belong to Tamil Nadu as verified from the Military Discharge Certificate (2) No patient in the above list is in receipt of pocket money from any other source. Ref No. & Date : Station : Signature of Superintendent of the Hospital To The Assistant Director, Ex-Servicemen Welfare Office, -----------------------------------District
