Annexure ‘A’

PROFORMA 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 GOVT. FIX PHOTO OF 1ST FIX PHOTO OF 2nd

OFFICIAL CHILD CHILD

1. Name of the Employee :

2. P.F. No./Employee No. :
3. Designation :
4. Present Department/Office :
5. Name of Spouse :
6. If spouse is employed, State whether :
in Central Govt., PSU, State Govt.
(give details)
7. Name, Designation and Office address :
of the Spouse.
8. Details of the children for whom CEA/Hostel Subsidy claimed:

Sl. No. Sequence Name DOB Age

1. 1st 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:
Page | 1
 (c) Date of disability certificate.
(d) Indicate the percentage of disability:
14. Whether the Bonafide certificate from Head of Institution has been attached:
Yes/No.
15. For Hostel Subsidy, the Bonafide certificate from mentioning the amount is
attached: Yes/No
16. If Yes at Item No. 15, Amount claimed for Hostel Subsidy:………………….
17. (i) Certified that the fee/amount indicate above had actually been paid by me.
(ii) Certified that my wife/husband is/is not a Central Government 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 child mentioned above.
(iv) Certified that I or my wife/husband has not claimed this re-imbursement from
any other source and will not claim the same in future.
18. 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.
19. 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:
Design:
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

Page | 2
 SELF DECLARATION
I _ ___________ do hereby certify that my

son/daughter namely ______________ Studied in Class ____ ___

Section _ Roll No. __ during previous

Academic year ____________________________________________ in

___________________________________________ _______ School.

(document 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 made to me”.

Signature of Govt. Servent

Name: _____________ .

Designation: ___________ .

CPIS NO: _______________ .

Place: __________________

Date: ___________________

Page | 3
 Annexure ‘C’
NOMINATION FORM AVAILING GRANT OF CHILDREN EDUCATION
ALLOWANCE
VIDE GOVT. ORDER NO. 473-F OF 2019 DATED 28-11-2019
I __________________________________ CPIS NO ___________________
do solemnly declare on oath that my family details is as under:-
Details of the family as on ______________________
Name of the Relationship
Date of
S.No. members of with the Occupation Aadhaar No.
Birth
family official
(1) (2) (3) (4) (5) (6)

Serial No’s _____ & ______ are my eldest wards (first two
children) for whom I am claiming Children Education Allowance / Hostel
Subsidy in terms of Govt. Order No. 473-F of 2019 dated 28-11-2019.

I also certify that my spouse

is not a Govt. employee

is a Govt. employee and NDC is enclosed.

The information given above is genuine to the best of my belief

and nothing has been concealed therein. In case the information given
above found to be false at any later stage, I shall be personally
responsible for legal action.

Signature __________________

Name: ___________________________

Place of Posting:_________________________

Place:

Date:
Page | 4