Affidavit for Medical Reimbursement

I, ________, son of/wife of ________, resident of House ________, do hereby solemnly affirm and declare as under:

1. That I state that I am dependent of ________ who ________.
2. That I further state that my ________ was admitted in ________ on ________ as ________ was suffering from ________ and ________ was in a ________ condition. During my treatment, ________ have spent approximately ₹ ________ towards hospital expenditure.
3. That I further state that I am entitled for medical reimbursement from the ________.
4. That I further state that I am drawing my ________ vide ________.

Deponent

Verification

Verified that the contents of my above said affidavit are true and correct to the best of my knowledge and belief, and nothing has been concealed therein.

Verified at ________ on ________.

Deponent

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