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Get Medical Reimbursement Form Karnataka

4. Place of duty . 5. Full residential address.. 6. Name of the Patient and his/her relationship to the Government servants/ Note :- In the case of children, state age also. 7. Place at which the patient fell ill 8. Nature of illness and its duration 9. Details for the amounts/claimed 10. Total amount claimed 11. List of enclosures 12. Countersignature by the controlling officer 1 Inserted in Notification No. DPAR 5 SMR 84 dated: 11th June 1985 Declaration to be signed by the Government S.

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