Date : 20-7-2011 From G. Suryanarayana, Zonal Manager (Retd), APIIC LTD., TIRUPATHI H.No. 20-164, Hanumesh Nagar, GUNTAKAL.

Anantapur Dist. To The Vice Chairman and Managing Director, APIIC LTD., Parisrama Bhavan, 6th Floor, HYDERABAD. THROUGH PROPER CHANNEL Sir, Sub : Estt G. Suryanarayana, Zonal Manager (Retd), APIIC LTD., E.Code No. 1133 Re-imbursement of Medical Expenses incurred For treatment Bills submitted Reg ---0o0--I, G. Suryanarayana, Zonal Manager (Retd), APIIC LTD., Tirupathi, E.Code No. 1133 submit the following few lines for favour of kind perusal and for consideration, Please. I submit that I have suffered from Nosal problem and as per Doctor s advise I underwent Nosal Surgery on 23-6-2011 at Kurnool. In this connection, I submit to inform that I have incurred an amount of Rs. 7,313-50 (Rupees Seven thousands three hundred and thirteen and paise fifteen only) for my treatment as follows: S.No 1. 2. Bill No. --26 Date 22-6-2011 23-6-2011 Description Lab Testing charges Hospital charges and Doctor s Fee 3. 352 23-6-2011 Medicines 213-50 Rs. Amount 600-00 6,500-00

----------------------------------------------------------------------------------------------------------------------------------------Total Rs. 7,313-50

Page No. 2

I am submitting herewith the original Bills (1) Bill No. nil dated 22-6-2011 of M/s. Sai Lahari Clinics, Kurnool for Rs. 600-00, (2) Bill No. 26 dated 23-6-2011 for Rs. 6,500-00 of M/s. Vijaya Hospital, Kurnool and (3) Bill No. 352 dated 23-6-2011 for Rs. 213-50 of M/s. Lahari Pharma, Kurnool and (4) Discharge Card of M/s. Vijaya Hospital, Kurnool. I therefore request the Vice Chairman and Managing Director to kindly consider my request and sanction Special Medical reimbursement of Medical Expenses of Rs. 7,313-50.

Thanking you Sir,

Yours faithfully

Encls: 1. Bills in Original 2. Annexures A & B. 2 Nos.

(G. Suryanarayana) Zonal Manager (Retd) APIIC LTD; TIRUPATHI.

Endt. No.

Date:

Submitted to the Vice Chairman and Managing Director, APIIC LTD., HYDERABAD for favour of kind consideration.

ZONAL MANAGER APIIC LTD: TIRUPTHI To The Vice Chairman and Managing Director, APIIC LTD., HYDERABAD.

PROFORMA A

Sub: Ref:

Special Reimbursement of Medical Expenses Application of the individual dated: ---0o0---

The following individual has requested for reimbursement of Medical Expenses as follows:

1. 2. 3. 4. 5. 6. 7.

Name : G. SURYANARAYANA Emp. Code No. : 1133 Designation : Zonal Manager (Retd) Place of working : Worked at Tirupathi The incumbent has worked as Zonal Manager at Tirupathi and retired on 31-1-2011. Bills submitted : Original Bills enclosed Amount Claimed : Rs. 7,313-50

ZONAL MANAGER APIIC LTD: TIRUPATHI

ANNEXURE - A

1. Name of the Employee

: G. SURYANARAYANA

2. Designation of the employee 3. Employee Code No. 4. Place of working

: Zonal Manager (Retd) : 1133 : Worked at Tirupathi

S.No. 1. 2. 3. 4.

Name of the Family Member G. Suryanarayana G. Uma G. Pavan Kumar G. Srikanth

Date of Birth 1-2-1953 18-6-1967 5-3-1984 19-9-1985

Relation ship Self Wife Son Son

SIGNATURE OF THE EMPLOYEE

// COUNTERSIGNED //

ANNEXURE - B

I, G. Suryanarayana, Zonal Manager (Retd), APIIC LTD., Tirupathi, Emplloyee Code No. 1133 certify as follows: 1. The claim pertains to myself 2. The amount of Rs. 7,313-50 (Rupees Seven thousand three hundred and thirteen and paise fifty only) towards reimbursement of Medical expenses was not claimed by me earlier nor claimed by any other person from any other sources and the same will not be claimed in future from any other source.

SIGNATURE OF THE EMPLOYEE Designation: Zonal Manager (Retd) Code No. 1133

// COUNTERSIGNED //