MEDICAL EXPENSE CLAIM FORM FOR TAX BENEFIT Employee Code Employee Name Location Date of Joining Financial Year ‘Sr. | Name of the Patient Fela ‘Aitending Doctor] Amount No. Total Claim Amount Verification: Hl do hereby certity that all expenses have been actually incurred by me for the medical treatment for self and family members as mentioned above. In the event the details provided above is found to be false or untrue and as a consequence, if any liabilly in the form of tax, interest ar penalty arises then I would be fully responsible for the same and | would reimburse the same to the company with any other cost / expenses incurred by the company. Date: INSTRUCTIONS: 1) Tax Benefit on Medical Allowance * Medical allowance received by the employee in monthly salary is fully taxable unless claimed ‘exemption with supporting documents. Exemption can be availed up to a maximum of Rs.15,000 per annum for medical expenses incurred during the financial year. * Exemption is given to the employee only if the medical expense is actually incurred on his medical treatment or his family members. Family members include spouse, children and dependent parents, brothers or sisters of the employee. 2) Original copy of Bills, Receipts, etc, for the amount claimed to be submitted with details to be updated in statement overleat. 3) This form is to be submitted to Payroll Team on or before January 15 2018 or before leaving the organization in the event of discontinuation of services.oF No BINS Bil Date Name (Chemist Hospital) Doctor Pathology Lab Bil Amount Total Claim Amount