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Sno

Various Proformas

Heads

Immoveable property- form giving prior intimation Property


- 1966

Immoveable

Moveable property- intimation for seeking previous Moveable


sanction

APPLICATION FOR ISSUE OF NO OBJECTION


CERTIFICATEFOR OBTAINING PASSPORT

Application for sanction of child care leave


Leaves

Application for encashment of leave on average


pay (LAP)

Application for LAP/LHAP

Grant of leave not due

Medical reimbursement

PF Advances

House Building Advance

65

10

Advances

11

Application
for
purchase
car/cycle/scooter advance

12

Application
form
accommodation in the

13

.Electronic fund transfer -mandate form

14

Traveling allowance

15

Issue of no objection certificate and sanction of


leave to be availed - outside India

of

motor

for
reservation
holiday home

Form of agreement to be executed at the time of


drawing an advance for the purchase of a motor
vehicle

of Holiday home

For office use


only

Form-I.

Form giving prior Intimation or seeking previous sanction under Rule 18(2) of the Railway
Service (Conduct) Rules, 1966 for transaction in respect of immoveable property.
1. Name and designation :

2. Scale of Pay & present Pay:


3. Purpose of application- sanction for transaction/
Prior intimation of transaction.

4. Whether property is being acquired or disposed off.


5. Probable date of acquisition/disposal of property.
6. Mode of acquisition/disposal.
7. a) Full details about location, viz. Municipal, Street/Village, Taluka, District,
And State in which situated.
b) Description of the property, in case of cultivable land, and irrigated land.
c) Whether freehold or leasehold.
d) Whether the applicants interest in the property is in full or part, ( in case of
partial interest, the extent of such interest must be indicated)
e) In case the transaction is not exclusively in the name of the Government servant,
particulars of ownership and share of each member.
1. Sale/purchase price of the property. ( Market value in the case of gifts).
2. In case of acquisition, sources or source from which financed/proposed to be
Financed:
a) Personal Savings.
b) Other sources giving details.
3. In case of disposal of property, was requisite sanction/intimation obtained/given
For the acquisition (A copy of the sanction/acknowledgement should be attached)
4.

a) Name & address of the party with whom transaction is proposed to be made.

b) Is the party related to the applicant?


c) Did the applicant have any dealings with the party in his official capacity at any time or is
the applicant like to have dealings with him inthe near future.
d) How was the transaction arranged ? (Whether through any statutory body or a private agency
through advertisement or through friends and relatives. Full particulars to be given)
5. In case of acquisition by gift, whether sanction is also required under Rule-13 of the Railway
Service (Conduct) Rules,1966.
6. Any other relevant fact which the applicant may like to mention.
DECLARATION
______________________________________
hereby declare that the particulars given
above are true. I request that I may be given permission to acquired/disposed of property as
described above from/to the party/name is required in item 11 above.

OR
______________________________________hereby intimate the proposed acquisition/disposal
of property by the name ( detailed above. I declare that the particulars given above are true.
Signature ___________________
Designation___________________
Date_______________________

Note: 1. In (On above form, different portions may be read according to requirement.
2. Where previous sanction is asked for the application should be submitted at last 30 days
before the proposed date of the transactions.

FORM FOR GIVING INTIMATION FOR SEEKING PREVIOUS SECTION


UNDER RULE 18(3) OF THE COS (CONDUCT) Rules, 1964 FOR TRANSACTION
IN RESPECT OF MOVEABLE PROPERTY.

1. Name of the Government Servant.


2. Scale of pay & present Pay.
3. Purpose of application sanction for transaction/
Intimation of transaction.
4. Whether property is being acquires or disposed off.
5. a) Probable date of acquisition of disposal of property,
b)If the property is already acquire/disposed off actual
date of transaction.
6. a) Description of property ( i.e. Car/Scooter/Motor Cycle/
Refrigerator, Radio/Radiogram/Jewellery/ Loans/Insurance
Policy etc.
b) Make model and also registration No. In case of Vehicles, where
necessary.
7. Mode of acquisition/disposal/purchase/sale/Girft/Mortgage lease
O therwise.
8. Sale/Purchase price of the property market value in the case of
Gifts.
9. In case of acquisition, source of sources from which financed proposed to
be financed.
a) Personal Savings.
b) Other sources giving details.
10. In case of disposal of property was requisite sanction/intimation obtained/given
for its acquisition.
a) Copy of the sanction/acknowledgement should be attached).
11. a) Name & Address of the party with whom transaction is proposed to be made/
has been made.
b) Is the party related to he applicant, If so, state the relationship.
c) Did the application have any dealing with the party in his official capacity at any
Time, or is the applicant likely to have any dealing with him in the near future.
d) Nature of official dealings with the party.
e) How was the transaction arranged ? (Whether through any statutory body or a
probable agency through friends and relatives. Full particulars to be given.)
12. In the case of acquisition by Gifts whether sanction is also required under Rules-18 of
the CCS (Conduct) Rules, 1964.
13. Any other relevant fact which the applicant may like to mention.

DECLARATION:

I________________________________hereby declare that the particulars given above are true.


I, request that I may be given permission to the acquire/dispose off property as described above
from/to party whose name.

OR

I__________________________________ hereby intimae the acquisition/disposal off the


property by me as detailed above. I declare that the particulars given above are true.

Station _______________________
Signature______________________
Dated:________________________
Designation:___________________

Note:

1. In the above from different portions may be used accordingly.


2. Where previous sanction is asked for application should be submitted at least 30 days
before the proposed date of the transaction.

APPLICATION FOR NO OBJECTION CERTIFICATE FOR ISSUE OF PASS PORT

TO
______________________
______________________
_______________________

( THROUGH PROPER CHANNEL)

Sir,
I wish to obtain a pass port for visiting ________________________ I request that I may
kindly be granted No Objection Certificate to enable me to produce it before passport issuing
authority. The details of Bio-data and others are as under:
1. Name :
2. Fathers Name :
3. Designation :
4. Date of Birth :
5. Date of Appointment :
6. Pay Band with Grade Pay :
7. Division/Branch in which working :
8. Station of posting.
9. Present Residential Address : __________________________________

___________________________________
___________________________________
__________________________________
10. Permanent Address :

__________________________________
___________________________________
___________________________________
____________________________________

11. Place of residence during the last (2)


Two years.
12. Country for which passport is required.

I declare that :
1. I will abide by the provisions of Indian Passport Act, Indian Customs Act and any
other Acts of the Government of India.
2. I will not request for release of Foreign Exchange from Railways and will make my
own arrangements for finance as and when I intend to visit abroad.
3. I will get the approval & sanction of leave from the appropriate competent authority
every time before proceeding abroad.
4. I understand that the issue of passport will be subject to clearance from the Civil
Authorities Income Tax department.
5. I will not undertake to pursue any study or training while abroad without prior
permission of the Railway Administration.
6. I will not indulge in any of activity which may be prejudicial to the interests of my
country or any other country and my activities during visit/stay abroad will not effect
the friendly relations between my country and any other country/countries.
7. I will abide by the General conditions laid down by the Government of India from
time to time in this connection.
Yours faithfully,
Station :____________
Dated :_____________
Signature of the applicant with
address.

Note:
The following information/documents as required by Passport Issuing Authorities for AnnexureB may be provided:
1. Declaration regarding nationality of wife.
2. Three Passport size photographs with name mentioned on the back side of the photo.
3. Copy of Indentity Card issued by your office concerned.
4. Details of dependent family members with date of birth with relation.

NORTHERN RAILWAY

MEDICAL REIMBURSEMENT

A TO LETTER No. 494-E/C/III/EiV dated 24/3/99 31/3/99.

1.

Name of Employees/Ex/employee.

2.

Whether serving or retired.

3.

Designation.

4.

Office/Unit of Posting.

5.

Pay & scale of Pay of employee pay last


drawn in case of ex-employee.

6.

Name of Patient.

7.

Relationship with family employee for whom


Re-imbursement is claimed.

8.

Age of patient.

9.

Medical/

10.

Whether referred or non-referred.

11.

If referred by whom?

12.

Name of the Institution where treatment


is taken.

I/Card No.

13.

Date of Admission.

14.

Date of Discharge.

15.

Date of submission of claim.

16.

Reasons for delayed, submission of claim,


if delayed for more than 6 months.

17.

Total period of stay as indoor


Indoor patient.

18.

Reasons for long stay (if stayed for


More than 18 hrs.)

19.

Type of medical emergency.

20.

Was there no Railway/Govt. facility available dealer?

21.

Distance of the nearest Govt. Hospital


& whether facilities available there.

22.

Distance of the nearest Railway Hospital and


Whether facilities available there. If not, how far
Is the Railway Hospital with the facilities
available.

23.

Distance of the Private Hospital from


Residence/place of illness, where
Facilities availed.

24.

When the Railway Medical Officer was


Informed about such admission.

25.

Does the patient take any treatment


Before or after for the present sickness
(if this existed before) and if yes, when?

26.

Total amount claimed (with break-up of charges


(detailed instructions at (f) of feature below).

27.

Total number of enclosures.

Counter sign. of controlling

Signature of employee

Officer/Unfit Incharge

of employee/spouse

(In case of serving employee only)

Declaration to be signed by the person claiming medical re-imbursement.

I, hereby declared that the statements in the application arfe grue to the
best of my knowledge and belief and
i) that the person for whom medical expenses were incurred is wholly
dependent upon me.
ii) the medical expenses were incurred for self, (strike out which is not
applicable from (i) & (ii) above.

Station.

Signature of Railway Servant.

Dated.

Design. & office to which attested.

Foot-Note.

1.
2.
a)
b)
c)
d)

Item No.18,19,20,21,22,23,24 and 25 are applicable only for non-referred


cases.
Following documents should be attached wikththis proforma.
Employees/Retired employees application giving circumstances under
which he/she took treatment.
Photocopy of Medical /RELHS I.D.Card duly attested by Gazetted Officer.
Essentiality certificate issued by the treating Doctor of hospital
countersigned by Medical Supdt. Of the treating Hospital.
Discharge certificate /slip in original.

e)

Bills /Vouchers (in original) duly counter signed by treating


Officer/Authorized M.D).

f)

Detailed item wise break-up of all bills (this means all bills/vouchers
submitted at (a) above be reproduced in LEGIBLE MANNER for e.g.:

g)

Bill No.

Name of Chemist/Shop

Date

Description of Item

Quantity

Price

i)

ii)

iii)

iv)

Total

h) In case of referred cases, attach original referred slip.

Instructions for submission.

In referred cases, the application duly countersigned by controlling


officer/subordinate incharge should be submitted to the Medical Establishment from
where he/she was referred.

In un-referred cases, the application duly countersigned by controlling


officer/subordinate incharge should be submitted to the P Branch concerned to the
call set up for the purpose of handling Medical re-imbursement case.

FOR OFFICIAL USE ONLY:

I)
II)

In case of all cases being sent to Board.


In case of AGMs sanction for un-referred / Non-Govt. un-recognized
cases.

Vibrating views of G.M.

Vibrating views of FA & CAO.

Signature of C.A.O.

APPLICATION FORM FOR RESERVATION OF


ACCOMMODATION IN THE
HOLIDAY HOME AT
______________________________.

1.
Name of employee
________________________________________________
2.
III/IV

Designation
____________

_________________________

(A) Class

(B)
Gr. RS.
__________________
Rate of Pay __________________
3.

Department

(C)

_______________________

(a)

Place of work_________________ (b) Division_______________

(c)

Railway_______________(d) Rly. Telephone No._____________

4.

Date of Appointment ______________________________________

5.

Whether coming on leave s/No.____________________________

6.

Reservation required from ______________to_________________

7.

State, if alternative dates are acceptable in case of


accommodation is
not available for the dates applied for
Yes/No _______________from ___________to_______________

8.

State, if accommodation of the above, Holiday Homes was


availed in
previous year, if yes, give year.______________________

9.

Particulars of family member to accompany the applicant.

S.No.

Name (Sh/Smt)

Relation

Age

I, request that one unit in the holiday home at


____________may be allowed for the bonafied use of self and family as
particulars mentioned against item No.9 of the above proforma rules and
conditions regarding occupation of the holiday read by me explained to
me and I agree to abide the same.
I also certify that either myself or any member of my family
who will be accompanying me to the holiday home is not suffering from
any infectious deceases and the family members.
I, agree to pay to the authority concerned prescribed charges in
advance and hereby authorized my bill complying office to recover from
the salary the cost of any breaking of furnitures equipment and lasses
or any articles t the room that it be allotted for my use.
Forwarded for necessary action.

Signature of the Applicant.

(Signature & Designation of the immediate


/Sr. subordinate incharge officer)

Electronic Fund Transfer


Mandate Form

Name

Designation

Name of the
Bank

Address of
the Bank

Account No.

Type of Account

Current/Saving

MICR Code

RTGS/IFC
Code of the
Bank

I, hereby declare that the particulars given above are correct and complete.

Date:

Signature and Stamp

Address.

..

Phone No..

Counter Signature of the Bank Authority


With Bank Seal

G.A.31/S.R.C/G-1677
G-6

TRAVELLING ALLOWANCE
Branch
Division/District..Headquarters..
Journal of duties performed by Shri.for which to allowance for
..........is claimed
DesignationPay..Date of appointment
Rule by which governed.

Mont

No.

Tim

Time

h&

of

arrive

date

train

left

Station

Kilomet

Day/

Object of

Night

journey

Rate

er
Fro

To

Rs.

P.

10

(P.T.O.)

Continued from previous page-

10

It is certify that1

The T.A. claimed by me has not been claimed before & will not be claimed hereafter.

Conveyance charges claimed have actually been spent by me and according to local

Municipal rates.
3

Cheapest mode of conveyance was utilized.

The journey performed by road for conveyance has been claimed was over 1.6 K.M.

Signature of Officer Claiming T.A.


I hereby certify that Shri.was absent on duty from his
headquarters station during the period charged for in the bill on Railway business and that the
offer performed the journey by Rail/Sea/Air/Road and was allowed/not allowed
free.

Signature of Head of the Office


Controlling Officer
1

On T.A. Bills of transfer from one Railway to another a certificate whether or not a free

Pass or locomotion at Government express was allowed should be recorded.

Annexure C

APPLICATION FOR ISSUE OF NO OBJECTION


CERTIFICATE FOR GOING ABROAD FOR SANCTION OF
LEAVE TO BE AVAAILED OUTSIDE OF INDIA

To,
______________________________

Sir,

Sub: Issue of No objection Certificate and sanction of leave


to be availed
of outside India.

I am possession of passport No.________________ issued by _____________


which I have obtained on the basis of the No objection Certificate issued by
you vide No. _________________________dated_______________. He passport is
valid upto ____________________ I wish to proceed to _________for the purpose
of
I request that I may kindly be granted permission for the same.
My application of leave from __________________to ___________________ is
enclosed herewith.

My service particulars and other details are given below:-

1.

NAME

2.

FATHERs NAME

3.

DESIGNATION

4.

DATE OF BIRTH

____________________________

5.

DATE OF APPOINTMENT IN RAILWAY

____________________________

6.

GRADE & RATE OF PAY

7.

____________________________
____________________________
____________________________

DIVISION/BRANCH

____________________________
IN

WHICH

WORKING

____________________________
8.

STATION OF POSTING

____________________________

9.

PRESENT RESIDENTIAL ADDRESS.


____________________________

10.
11.

PERMANENT ADDRESS.
PLACE

OF

____________________________
RESIDENCE

DURING

THE

LAST

____________________________
2 YEARS.
12.

13.

PLACE OF VISIT ABROAD WITH

____________________________

NAMES OF THE COUNTRIES

____________________________

DURATION OF THE VISIT.

____________________________

14.

ADDRESS WHICH ABROAD.

____________________________

15.

ESTIMATED EXPENDITURE

____________________________

16 SOURCE OF FUNDS.

____________________________

17 If the transaction for the source of funds requires the prior sanction of
the
competent authority as per the Railway service/Conduct rules, 1968 (Rules
18) sanction particulars of the same.

I Declare that:-

1.
I will not request for release of foreign exchange from Railway and will
make my own arrangement for the foreign exchange required for the trip.

2.
I will not over-stay abroad excerpt with the prior approval of the
competent authority.
3.
I will make my own arrangement to get my leave salary and other
allowances while abroad. I understand that these amounts will be paid only
in Indian Rupees.
4.
I will not seek an financial / assistance
country/institution /agency for his/her itinerary.

from

any

foreign

5.
I will not peruse any study for training while abroad without prior
permission of the admn.,
6.

I will not take up any employment of activity of profit while abroad.

7.
I will not indulge in any activity which may be pre-judicial to the
interest of m my own country or any other foreign country and my activities
dignity visit/stay abroad will not affect the friendly relations between my
country and any other countries.
8.
I will inform any change of address which may take place during my
stay abroad to the Railway Administration.
9.
I will not enter into any contract or marriage with a person other than
Indian Nationality without prior permission of the Govt.
10. I will adhere to the provisions of Rule 18 of the Railway services
(Conduct Rules 1956 in case I enter into any transaction for moveable
property.
11. I clearly understand that I am liable for action under D&AR Rules in
case violate any of the above provisions at any conduct of unbecoming of a
Railway Servant I am abroad.

Yours faithfully,

Station.
Dated.
Signatures.

Signature of Applicant.
with Name below the

FORM OF AGREEMENT TO BE EXECUTED AT THE TIME OF DRAWING


AN ADVANCE FOR THE PURCHASE OF A MOTOR VEHICLE.
An agreement made on _________________ day of ________________ two thousand
_______________
hundred
_______________
between
_________________
of
__________________________( hereinafter called the Borrower which expression shall include
his heirs, administrators, executors and legal representatives) of the One Part AND the
President of India (Hereinafter called the President, which expression shall include his
successors and assignees) of the other part. WHEREAS, the Borrower has under the
provisions of the Indian Railway General Code (hereinafter referred to as the Paid code which
expression shall include any amendments thereof for the time being in force) applied to the
President for a loan of Rs._________________________________________ for the purchase of a
motor vehicle and WHEREAS the President has agreed to lend the said amount to the
Borrower on the terms and conditions hereinafter contained. NOW IT IS HEREBY AGREED
between the parties hereto that in consideration of the sum of Rs._______________________
paid by the President to the Bowwower ( the receipt of which the Borrower hereby
acknowledges) the Borrower hereby agrees with the President (1) to pay the President the
said amount with interest calculated according to the said Code by monthly deductions from
his salary as provided in the said Code and hereby authorizes the President to make such
deductions and (2) within one month from the date of these presents to expand the full
amount of the said loan in purchase of a Motor vehicle or if the actual price paid is less than
the loan to repay the difference to the President forthwith and (3) to execute the document
hypothecation the said motor vehicle to the President as security for the amount lent to the
Borrower is aforesaid and interest in the form provided by the said Code and IT IS HEREBY
LASTLY AGREED AND DECLARED THAT IF THE MOTOR VEHICLE has not been purchased and
hypothecated as aforesaid within one month from the date of these presents or if the
Borrower within that period becomes involvement or quit the service of the Government or
dies, the whole amount of the loan and interest accrued thereon shall immediately become
due and payable.
IN WITNESS WHEREOF THE BORROWER and for and on behalf of the President have
hereunto set their hands the day and year first become written.
* Signed by the said in presence of

1.

2.

Signature of witnesses

Station office

Date

(Signature and designation of Officer)

Station Office

Date

Signature of authority for and on

behalf of President for India