INDEX

[Link]. Check List Page No.

 Leave (LAP,LHAP) 03-04
1  Joinig Leave 05-06
 Encashment format 07
 Medical Benefits Declaration 08
 Indoor Treatment 09
 Outdoor Treatment 10
2
 Special Disease 11
 Hearing Aid/ Ophthalmic/ Dental 12
 Executive Health Check Up scheme(EHCS) 13
 LTC Declaration 14
3  LTC Advance 15-16
 LTC Claim 17-18
 Reimbursement of Mobile Instrument 19
 Brief Case 20
4
 Hard Disk Drive (HDD) 21
 Laptop & Accessories Charges 22-23
 Tour Programme 24
5  Tour Advance 25
 TA Claim 26
 Night Duty Allowance (NDA) 27
6  National Holiday Allowance (NHA) 28
 Daily Diary 29
7  Mutual Transfer 30
 Undertaking for application in another
8 31
Organization (before joining)
 CTG Claim (For Regular Employees) 32-33
9
 CTG Claim (For Deputation) 34
10  Application for disbursement under welfare Rules 35
 Higher Education 36-37
 Applications of “No Objection Certificate” for 38
11
external employment.
 No Objection Certificate for obtaining Passport 39-40
12  Option for Fixation of pay on Promotion 41
 3rd Party Lease Application 42
 Under taking 43
 3rd Party Lease Agreement 44
13  Self Lease Application 45-46
 Consent Letter for Self lease 47
 Self Lease Agreement 48
 No Demand Certificate 49
  Multipurpose Advance 50-51
14  Entertainment Allowance 52
 Hard & Soft Furnishing 53
15  Key Result Areas (KRAs) 54
 Immovable Property 55-56
 Liquid Assets 57
 Movable Property 58
16
 Provident Fund & Life Insurance 59
 Debts & Other Liabilities 60
 Annual Immovable Property Return 61
17  No Dues Certificate 62-66
18  Resignation from Service 67
 ƒ—ƒŽ‘ˆ  



$QQH[XUH,

'HGLFDWHG)UHLJKW&RUULGRU&RUSRUDWLRQRI,QGLD/LPLWHG$SSOLFDWLRQIRU/HDYH

1DPHRIDSSOLFDQW   BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

(PSOR\HH&RGH   BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

3RVWKHOG    BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

3ODFHRISRVWLQJ 'HSWW3URMHFW  BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

.LQGRI/HDYHDSSOLHGIRU  BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

3HULRG    BBBBBBB'D\V)URPBBBBBBBBWRBBBBBBBBBBB

3XUSRVH    BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

6DW6XQ+ROLGD\VWREH BBBBBBBBBBBBBSUHIL[HGBBBBBBBBBBBBBVXIIL[HG

:KHWKHULQWHQGVWRDYDLO/7&
,IVRPHQWLRQWKHEORFN\HDU 
QXPRIGD\VWREHHQFDVKHGLIDQ\ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB

$GGUHVVZKLOHRQ/HDYH  BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB


6LJQDWXUHRIWKHDSSOLFDQW
5HFRPPHQGDWLRQRIFRQWUROOLQJRIILFHU


2UGHUV RI WKH /HDYH VDQFWLRQLQJ DXWKRULW\ ,I WKH FRQFHUQHG 6LJQDWXUH 'DWH 
&30**0*0 LV WKH OHDYH VDQFWLRQLQJ DXWKRULW\ IRU WKH OHDYH 'HVLJQDWLRQ
DSSOLHGIRUWKHVDPHPD\EHVDQFWLRQHGVXEMHFWWRYHULILFDWLRQE\
+5 RI WKH OHDYH GXH DQG DGPLVVLEOH ,Q RWKHU FDVHV WKH OHDYH
DSSOLFDWLRQLIUHFRPPHQGHGPD\EHIRUZDUGHGWR+5&RUS2IILFH
IRUIXUWKHUSURFHVVLQJ




 

 ƒ‰‡ͳʹͷ

 ƒ—ƒŽ‘ˆ  



&(57,),&$7(5(*$5',1*$'0,66,%,/,7<2)/($9(

&HUWLILHGWKDW/$3/+$3&RPPXWHG/HDYH(2/BBBBBBBBBBBBBBBBBBBBBBBBBBBBBIRU
BBBBBBBBGD\VIURPBBBBBBBBBBBBBWRBBBBBBBBBBBBBBBDVDSSOLHGIRULVGXHDQGDGPLVVLEOH
XQGHUWKH/HDYH5XOHV

7KH EDODQFH RI OHDYH DW KLVKHU FUHGLW DV RQ BBBBBBBBBBBBBB ZLOO EH /$3BBBBBBGD\V
/+$3BBBBBBGD\V

7KH OHDYH DV DERYH KDV EHHQPD\ NLQGO\ EH VDQFWLRQHG E\ WKH FRPSHWHQW OHDYH
VDQFWLRQLQJDXWKRULW\



6LJQDWXUHRIWKHFXVWRGLDQRIOHDYHDFFRXQW 
'HVLJQDWLRQ
'DWH


'HVLJQDWHG+5RIILFHU








2UGHUVRIWKH/HDYHVDQFWLRQLQJDXWKRULW\IRUWKHOHDYHDSSOLHGIRU
6LJQDWXUH'DWHDQG'HVLJQDWLRQ 
2UGHUV WR EH REWDLQHG E\ +5 RQO\ LQ WKRVH FDVHV ZKHUH WKH OHDYH VDQFWLRQLQJ
DXWKRULW\LVDQDXWKRULW\KLJKHUWKDQWKHFRQFHUQHG&30**0*0 



&RS\RIWKHVDQFWLRQRIOHDYHWR

 7KHFRQFHUQHGHPSOR\HHIRULQIRUPDWLRQ
 /HDYHVDQFWLRQLQJDXWKRULW\IRULQIRUPDWLRQ
 7KHFRQFHUQHG)LQDQFHRIILFHUIRUPDNLQJQHFHVVDU\DGMXVWPHQWVZKLOH
GHWHUPLQLQJ/HDYH6DODU\&RQWULEXWLRQVLQWKHFDVHVRI'HSXWDWLRQLVW
 3HUVRQDO)LOHRIWKHHPSOR\HH 

 ƒ‰‡ͳʹ͸

7
8
10
 ƒ—ƒŽ‘ˆ  


$QQH[XUH²,

0(',&$/%(1(),76'(&/$5$7,21

,FHUWLI\WKDWP\IDPLO\PHPEHUVVWDWHGEHORZDUHGHSHQGHQWXSRQ
PH DV SHU ')&&,/ 0HGLFDO 5XOHV DQG DQ\ FKDQJH LQ WKH VWDWXV LQ WKLV
UHVSHFWVKDOOEHLPPHGLDWHO\LQWLPDWHGWR+5&RUS2IILFH

61 1DPH '2% 5HODWLRQVKLS 5HPDUNV
ZLWKHPSOR\HH
    
    
    
    
    
    
    

 ,EHLQJRQGHSXWDWLRQWR')&&,/RSWWRDYDLOWKHPHGLFDOEHQHILWV
RIWKHFRPSDQ\DQGVKDOOQRWDYDLOWKHEHQHILWVIURPP\SDUHQW
GHSDUWPHQW

)RUGHSXWDWLRQLVWVRQO\


1DPHBBBBBBBBBBBBBBBBBBBBBBBB
6LJQDWXUHBBBBBBBBBBBBBBBBBBB
'HVLJQDWLRQBBBBBBBBBBBBBBBBBBB
'DWHBBBBBBBBBBBBBBBBBBBBBBBBBB


&RQWUROOLQJ2IILFHU



+5&RUS2IILFH
 

 ƒ‰‡ͳͳͳ

 ANNEXURE-II

Sub: Reimbursement of medical expenses on Indoor Treatment under DFCCIL Medical Rules.
1 Name of the employee
2 Employee Code
3 Designation & Place of posting
4 Scale of Pay & Basic Pay
5 Name of the patient
6 Employee’s Relationship with the patient.
Name & Address of the Hospital
7
Registration No. of the hospital with
8
Central/State Govt./Local Bodies :
9 Date of Admission in the hospital
10 Date of Discharge from the hospital
Diagnosis of the ailment and treatment
11
given in brief.
Details of the amount claimed are given
12
below:
Details of the amount claimed (attach details as per format below in a separate sheet, if the space is not
13
adequate)
Bill Gross amount
14 Details Amount claimed*
No./date of bill
A Medicines

B Consultation charges

C Investigation charges

D Room Rent

GROSS TOTAL:
* All bills/cash-memos (in original)/supporting prescriptions (clearly indicating the diagnosis)/reports duly
verified must be enclosed.

DECLARATION/UNDERTAKING:

1. The claim for reimbursement is being made for self/family members, who are covered under the
definition of ‘Family’ under the DFCCIL Medical Rules as on the date of treatment.
2. The amount claimed is only for in respect of treatment of specified Special Disease only. No other
medicines/expenses are claimed for reimbursement.
3. The claimed expenditure has actually been incurred by me.
4. In case of multiple diseases covered in the same prescription, the amount claimed is restricted to
the treatment of specified Special Disease only.
5. Reimbursement is claimed for only one system of treatment for the specified Special Disease only.
6. Misuse, fraudulent use, false declaration, or false claims for reimbursement will render me liable
to refund the amount with penal interest besides initiation of disciplinary action as per extant
rules.

Signature of the employee : _____________________

Date : _____________________

Recommendation of the Controlling Officer

________________________________________________

Name:

Designation:
 ANNEXURE-III-A

Sub: Reimbursement of medical expenses on Investigations (Outdoor) under DFCCIL Medical Rules.
1 Name of the employee
2 Employee Code
3 Designation & Place of posting
4 Scale of Pay & Basic Pay
5 Name of the patient
6 Employee’s Relationship with patient
7 Disease diagnosed by the AMA
/presence of symptoms
(to be specifically mentioned in the prescription)
8 Name/s of AMA with Regn No.
9 Details of the amount claimed are given
below:
10 Details Bill No./date Gross amount of bill Amount claimed*
A Investigation charges (head-wise)

GROSS TOTAL:
* All bills/cash-memos (in original)/supporting prescriptions (clearly indicating the diagnosis/presence of
symptons)/lab reports, etc. duly verified must be enclosed.

DECLARATION/UNDERTAKING:

1. The claim for reimbursement is being made for self/family members, who are covered under the
definition of ‘Family’ under the DFCCIL Medical Rules as on the date of treatment.
2. The claimed expenditure has actually been incurred by me.
3. Misuse, fraudulent use, false declaration, or false claims for reimbursement will render me liable to
refund the amount with penal interest besides initiation of disciplinary action as per extant rules.

Signature of the employee : _________________________

Date : _______________________

Recommendation of the Controlling Officer

________________________________________________

Name:

Designation:
 ANNEXURE-III

Sub: Reimbursement of medical expenses on Special Disease under DFCCIL Medical Rules.
1 Name of the employee
2 Employee Code
3 Designation & Place of posting
4 Scale of Pay & Basic Pay
5 Name of the patient
6 Relationship with the employee
7 Disease diagnosed by the AMA
(to be specifically mentioned in the prescription)
Details of the amount claimed are
8
given below:
9 Name/s of AMA with Regn No.
10 Details Bill No./date Gross amount of bill Amount claimed*
A Medicines

B Consultation charges

C Investigation charges

GROSS TOTAL:
* All bills/cash-memos (in original)/supporting prescriptions (clearly indicating the diagnosis)/reports duly verified
must be enclosed.

DECLARATION/UNDERTAKING:

1. The claim for reimbursement is being made for self/family members, who are covered under the definition
of ‘Family’ under the DFCCIL Medical Rules as on the date of treatment.
2. The amount claimed is in respect of treatment of specified Special Disease only. No other
medicines/expenses are claimed for reimbursement.
3. The claimed expenditure has actually been incurred by me.
4. In case of multiple diseases covered in the same prescription, the amount claimed is restricted to the
treatment of specified Special Disease only.
5. Reimbursement is claimed for only one system of treatment for the specified Special Disease only.
6. Misuse, fraudulent use, false declaration, or false claims for reimbursement will render me liable to refund
the amount with penal interest besides initiation of disciplinary action as per extant rules.

Signature of the employee: _________________________

Date : _________________________

Recommendation of the Controlling Officer

________________________________________________

Name:

Designation:
 ANNEXURE-III-B

Sub: Reimbursement of medical expenses on Hearing Aid/ Ophthalmic/ Dental under

para-4 (d) of DFCCIL Medical Rules.
1 Name of the employee
2 Employee Code
3 Designation & Place of posting
4 Scale of Pay & Basic Pay
5 Name of the patient
6 Employee’s Relationship with patient
7 Disease diagnosed by the AMA /claims
made for type of treatment
(to be specifically mentioned in the prescription)
8 Name/s of AMA with Regn No.
9 Details of the amount claimed are given
below:
10 Details Bill No./date Gross amount of bill Amount claimed*
A Consultation/s

B Investigation charges (head-wise)

C Procedures (detailed break up)

GROSS TOTAL:
* All bills/cash-memos (in original)/supporting prescriptions (clearly indicating the diagnosis/presence of
symptons)/lab reports, etc. duly verified must be enclosed. Claims to be made only for specified
treatments given in the Medical Rules and all required documents to be attached.

DECLARATION/UNDERTAKING:

1. The claim for reimbursement is being made for self/family members, who are covered under the
definition of ‘Family’ under the DFCCIL Medical Rules as on the date of treatment.
2. The claimed expenditure has actually been incurred by me.
3. Misuse, fraudulent use, false declaration, or false claims for reimbursement will render me liable
to refund the amount with penal interest besides initiation of disciplinary action as per extant
rules.

Signature of the employee : _________________________

Date : _______________________

Recommendation of the Controlling Officer

________________________________________________

Name:

Designation:
Sub: Reimbursement of expenses under Executive Health Check Up scheme(EHCS)

Name of Employee (Date of Birth) /

1.
Name of the Spouse (Date of Birth)

2. Employee Code

3. Designation and Place of Posting

4. Scale of Pay and Basic Pay

Date of last re-imbursement taken if

5.
any under EHCS

Whether copy of reports and verified

6.
original bills enclosed

7. Total amount claimed

Signature of the employee : _________________________

Date : _______________________

Recommendation of the Controlling Officer

________________________________________________

Name:

Designation:
 ƒ—ƒŽ‘ˆ  

$QQH[XUH²,

'HFODUDWLRQRI+RPH7RZQDQGGHSHQGHQWIDPLO\
PHPEHUV
, 1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 'HVLJQBBBBBBBBBBBBBBBB (PS 1R
BBBBBBBB 6FDOH RI 3D\ BBBBBBBBBBBBBBBBBBBBB 5DWH RI 3D\ BBBBBBBBBBBB '2$$EVRUSWLRQ
BBBBBBBBBBBBBBBBBBBBBBB KHUHE\ GHFODUH WKDW P\ +RPH 7RZQ IRU WKH SXUSRVH RI /7& LV
BBBBBBBBBBBBBBBBBBBBBBB IDLOLQJ ZLWKLQ WKH 'LVWULFW BBBBBBBBBBBBBBBBBBBBBBBBBBB RI 6WDWH
BBBBBBBBBBBBBBBBBBBB

,IXUWKHUGHFODUHWKDWP\VSRXVHDQGRWKHUIDPLO\PHPEHUVZKRDUHZKROO\GHSHQGHQW 
XSRQPHFRQVLVWVRIWKHIROORZLQJPHPEHUVZLWKWKHUHOHYDQWSDUWLFXODUVVKRZQDJDLQVWHDFK
LQWKHWDEOHEHORZ,VKDOOQRWLI\WKHFKDQJHVLIDQ\DVDQGZKHQDULVH

6O 1DPHRI)DPLO\PHPEHUV 6H[ 'DWH RI $JH 5HODWLRQVKLS

1R LQFOXGLQJVHOI %LUWK
     







3OHDVHUHIHUWR5XOH E   F RIWKH')&&,/ /7& 5XOHV

3ODFH       6LJQ

'DWH       'HVLJQDWLRQ

&RQWUROOLQJ2IILFHU

 

 ƒ‰‡ͳ͵͹

 ƒ—ƒŽ‘ˆ  

$QQH[XUH²,,

$SSOLFDWLRQ)RUPIRU*UDQWRI/7&$GYDQFH
61 3DUWLFXODUV 'HWDLOV
 1DPH 'HVLJQDWLRQRIWKH$SSOLFDQW 
LQEORFNOHWWHU (PS1R 

 'DWHRI-RLQLQJ')&&,/ 
 3UHVHQW 3D\  *UDGH SD\ RU SUHVHQW 
,'$3D\VFDOH 

 1DWXUH SHULRGRIOHDYHVDQFWLRQHG 


 3DUWLFXODUV RI PHPEHUV RI ¶)DPLO\· 1DPH DJH 5HODWLRQVKLS
LQFOXGLQJ VHOI  LQ UHVSHFW RI ZKRP  
/7&LVSURSRVHGWREHDYDLOHG  
  
  
  
  


 D  1DPH RI WKH SODFH WR EH YLVLWHG 

ZLWK WKH QHDUHVW UDLOZD\ VWDWLRQ LQ
EORFNOHWWHUV 
E  ´+RPH 7RZQµ DV GHFODUHG XQGHU
WKHUXOH
F  6SHFLILFDOO\ PHQWLRQ WKH EORFN IRU
ZKLFK/7&LVWREHDYDLOHG
 3UREDEOH GDWH RI FRPPHQFHPHQW RI 
WKHMRXUQH\
 6LQJOH UDLO IDUH  EXV IDUH IURP WKH 
KHDGTXDUWHUVWRKRPHWRZQSODFHRI
YLVLWE\VKRUWHVW URXWHLQWKHHQWLWOHG
PRGHFODVV
 $PRXQWRI/7&DGYDQFHUHTXLUHG 


$ &HUWLILHGWKDW
D ,DPDYDLOLQJRIWKHFRQFHVVLRQIRUWKHILUVWWLPHGXULQJWKHEORFN\HDUVBBBBBBBB
E 7KH)DPLO\ PHPEHUV LQ UHVSHFW RI ZKRVH MRXUQH\ V  WKH DGYDQFH LV EHLQJ FODLPHG
DUHHQWLUHO\GHSHQGHQWXSRQPH
F 7KDWP\ZLIHKXVEDQGLVQRWDQHPSOR\HHRI')&&,/+H6KHKDVQRWDYDLOHGRI
WKHFRQFHVVLRQVHSDUDWHO\
G 7KDWWKHMRXUQH\ V VKDOOEHSHUIRUPHGE\WKHFODVVRIDFFRPPRGDWLRQIRUZKLFKWKH
DGYDQFHKDVEHHQGUDZQ

 ƒ‰‡ͳ͵ͺ

 ƒ—ƒŽ‘ˆ  

% ,XQGHUWDNH
D 7R UHIXQG WKHDGYDQFH LQ IXOO IRUWKZLWK LI WKH RXWZDUG MRXUQH\ LV QRW FRPPHQFHG
ZLWKLQGD\VRIWKHGUDZDORIDGYDQFH
E 7RUHIXQG WKH&RPSDQ\ RQHKDOI RI WKHDGYDQFHIRUWKZLWKZKHUHWKH DGYDQFHKDV
EHHQ GUDZQ IRU ERWK WKH RXWZDUG DQG UHWXUQ MRXUQH\ DQG ODWHU LW EHFRPHV FOHDU
WKDWWKHSHULRGRIDEVHQFHIURPKHDGTXDUWHUVLVOLNHO\WRH[FHHGGD\V
F 7RVXEPLWWKH/7&FODLPDORQJZLWKMRXUQH\WLFNHWVFDVKUHFHLSWVHWFDJDLQVWWKH
DGYDQFHGUDZQZLWKLQGD\VDIWHUWKHFRPSOHWLRQRIWKHUHWXUQMRXUQH\

,GHFODUHWKDWWKH SDUWLFXODUV IXUQLVKHGDERYHDUHWUXHDQGFRUUHFW WR WKHEHVWRI P\
NQRZOHGJH,XQGHUWDNHWRUHWXUQWKHDGYDQFHLQRQHOXPSVXPLQFDVHWKHRXWZDUGMRXUQH\
LVQRWFRPPHQFHGZLWKLQGD\VRIUHFHLSWRIWKHDGYDQFH

'DWHGBBBBBBBBBBBBBB   6LJQDWXUHRIWKH(PSOR\HH

&RQWUROOLQJ2IILFHU

 

 ƒ‰‡ͳ͵ͻ

 ƒ—ƒŽ‘ˆ  

  $QQH[XUH²,,,

/7&&ODLP)RUP
 1DPHRIWKHHPSOR\HH 
 'DWHRIDSSRLQWPHQW 
 'HVLJQDWLRQ'HSDUWPHQW 
 (PSOR\HH1R 
 %DVLFSD\DQGVFDOH 
 3HULRG QDWXUHRIOHDYHDYDLOHG 
 L %ORFN\HDUGXULQJZKLFKWKH 
FRQFHVVLRQODVWDYDLOHGRI
 LL %ORFN\HDUVGXULQJZKLFKWKH 
FRQFHVVLRQQRZDSSOLHGIRU
 3OHDVHLQGLFDWHWKHW\SHRI/7&LH 
+RPH7RZQRU$OO,QGLD

 3ODFHRIYLVLW 

'HWDLOVRIMRXUQH\XQGHUWDNHQ SOHDVHHQFORVHMRXUQH\WLFNHWVFDVKUHFHLSWVHWF 

61 1DPH 5HODWLRQVKLS 'DWHRI )URP 7R 'LVWDQFH 0RGH )DUH

$JH -RXUQH\
287:$5'-2851(<
        
        
        
        
        
5(7851-2851(<
        
        
        
        
        


 $PRXQWRIIDUHFODLPHGDVSHUUXOHV BBBBBBBBBBBBBBBBBBBBBBBB

 $PRXQWRIDGYDQFHWDNHQLIDQ\  BBBBBBBBBBBBBBBBBBBBBBBB
 %DODQFHDPRXQWSD\DEOHUHFHLYDEOH BBBBBBBBBBBBBBBBBBBBBBBB


'DWHBBBBBBBBBB     6LJQDWXUHRIWKHHPSOR\HH

&RQWUROOLQJ2IILFHU
372 

 ƒ‰‡ͳͶͲ

 ƒ—ƒŽ‘ˆ  



&KHFNOLVWIRU6FUXWLQL]LQJDQGSURFHVVLQJRI/7&FODLPV
7KHIROORZLQJSRLQWVVKRXOGEHNHSWLQYLHZZKLOHVFUXWLQL]LQJDQGSURFHVVLQJWKH/7&
FODLPV

L :KHWKHUWKHHPSOR\HHKDVFRPSOHWHGRQH\HDURIFRQWLQXRXVVHUYLFHRQWKH
GDWHRIMRXUQH\
LL :KHWKHU WKH FODLP KDV EHHQ SUHIHUUHG ZLWKLQ RQH PRQWK  WZR PRQWKV RI
WKHGDWHRIFRPSOHWLRQRIWKHUHWXUQMRXUQH\
LLL :KHWKHUWKHFODLPLVIRUWKHMRXUQH\SHUIRUPHGZLWKLQ,QGLD
LY :KHWKHUWKHKRPHWRZQLVWKHSHUPDQHQWKRPHWRZQUHFRUGHGLQWKHVHUYLFH
ERRNRUDVGHFODUHGE\WKHHPSOR\HHIRUWKLVSXUSRVH
Y 5HODWLRQVKLSRIWKHPHPEHUVRIWKHIDPLO\DQGDJH
YL :KHWKHUWKHHPSOR\HHLVHQWLWOHGWRWKHFODVVRIDFFRPPRGDWLRQE\ZKLFKKH
KDVWUDYHOOHG
YLL :KHWKHUWKHFODLPLVE\WKHVKRUWHVWURXWH
YLLL :KHWKHU WKH HPSOR\HH KDV SUHYLRXVO\ LQWLPDWHG EHIRUH WKH MRXUQH\ ZDV
XQGHUWDNHQ
L[ :KHWKHU SURRI RI MRXUQH\ LHUDLOZD\ WLFNHWV  FDVK UHFHLSWV  EXV WLFNHWV
HWFVXEPLWWHG
[ :KHWKHU WKH FRQFHVVLRQ KDV EHHQ DYDLOHG DV SHU WKH HQWLWOHPHQW LQ WKH
UHOHYDQWEORFN\HDU
[L :KHWKHU WKH DGYDQFHWDNHQ KDV EHHQ DGMXVWHG LQ IXOO RU WR EH UHFRYHUHG 
UHIXQGHG

 ƒ‰‡ͳͶͳ

 Reimbursement of Mobile Instrument

The Dy. Chief Project Manager/S&T,

DFCCIL, _____________________.

Subject: Reimbursement of Expenses incurred for Purchase of New Mobile

Instrument.

Sr. No. Particulars Remarks (if any)

1 Previous Date of Purchase:

2 Entitlement Limit:

3 Invoice Number:

4 IMEI Number:

5 Claimed Amount:

6 Invoice/Paid Amount:

7 Date of Invoice:

Signature :
Name of the Officer :
Designation :
Employee ID :
CUG Mobile No. :

* All supporting Documents to be signed and attached while submitting this format.
** All claims to be submitted in original invoice.
Reimbursement Admissible for Rs.

SAP Document Generated during Entry:

SAP Document Generated during Payment:
 Reimbursement of Brief Case

The Dy. Chief Project Manager/S&T,

DFCCIL, _____________________.

Subject: Reimbursement of Expenses incurred for Purchase of Brief Case.

Sr. No. Particulars Remarks (if any)

1 Previous Date of Purchase:

2 Entitlement Limit:

3 Invoice Number:

4 Claimed Amount:

5 Invoice/Paid Amount:

6 Date of Invoice:

Signature :
Name of the Officer :
Designation :
Employee ID :
CUG Mobile No. :

* All supporting Documents to be signed and attached while submitting this format.
** All claims to be submitted in original invoice.
Reimbursement Admissible for Rs.

SAP Document Generated during Entry:

SAP Document Generated during Payment:
 Reimbursement of Hard Disk Drive (HDD)

The Dy. Chief Project Manager/S&T,

DFCCIL, _____________________.

Subject: Reimbursement of Expenses incurred for Purchase of Hard Disk Drive.

Sr. No. Particulars Remarks (if any)

1 Previous Date of Purchase:

2 Entitlement Limit:

3 Invoice Number:

4 Serial Number:

5 Claimed Amount:

6 Invoice/Paid Amount:

7 Date of Invoice:

Signature :
Name of the Officer :
Designation :
Employee ID :
CUG Mobile No. :

* All supporting Documents to be signed and attached while submitting this format.
** All claims to be submitted in original invoice.
Reimbursement Admissible for Rs.

SAP Document Generated during Entry:

SAP Document Generated during Payment:
 Date: ____________________

The GM/Co-ordination,
DFCCIL,
____________________ .

Sub: Reimbursement against Purchase of Laptop & Accessories Charges.

The undersigned have purchased a laptop of _________________________________,

Serial No. __________________________, Invoice No. ______________________________, Invoice
Date ________________________ of Rs. _______________________ from
______________________________________ for day to day official use. Original bills are
enclosed herewith. Details are as under:

Basic Cost of Laptop: __________________ + _______________ (GST) = Rs. _______________

Maintenance of Laptop: _______________ + _______________ (GST) = Rs. _______________

Total Amount Claim = __________________

As per the latest laptop policy no. HQ/IT/Policy/01, dated 15.01.2019, I am

eligible for purchase of laptop & accessories worth Rs.________________ + GST for 3 years
as applicable.

It is therefore requested that the sum of Rs. ________________________ towards

purchase of laptop, may kindly be reimbursed to my account.

The earliest date of purchase is on __________________________. Residual amount

paid receipt is also enclosed.

Undertaking:
"Claim, which I am submitting is within my entitlement limit and I am entitled for this
claim as per rule. It is also certified that this claim I have not taken earlier."

Emp. Name : _________________________________

Designation : ________________________________
Emp ID : _____________________________________

Place of Posting : ___________________________

Encl.: As Above
 Undertaking for Laptop Procurement / Repair Claim

The Laptop model ______________________ with serial no. ___________________

has been actually procured / got repaired & maintained by the undersigned.

The reimbursed amount is liable to be recovered from undersigned in case of false

declaration detected at a later date.

The complete onus of ensuring and certifying authenticity and correctness of submitted
documents at the time of claiming reimbursement shall lies with the undersigned (claiming
Official) and not on the sanctioning authority.

Emp. Name : _________________________________

Designation : ________________________________
Emp ID : _____________________________________

Place of Posting : ___________________________

 दौरा कार्यक्रम Tour Programme

नाम/Name: ______________________________________________________
पदनाम/Designation: _______________________________________________

ददनाांक/ र्ात्रा का कहाां से/गाडी/फ्लाइट कहाां तक/गाडी उददेश्र्/

Dated माध्र्म/ सांख्र्ा/रस्‍ ान समर् सांख्र्ा/आगमन Purpose
Mode of From/Train/Flight समर्
Journey No./Departure To/Train
time no./Arrival
Time

कृपर्ा अनुमोदना य रस्‍तुत ह/Put up for Approval please.

( )

Controlling officer / दनर्ांत्रण अदिकारी

 Annexure

TOUR ADVANCE FORM

t Name
2 Emp Code
3 Designation
4 Place of posting
5 Place of visit

6 Purpose of the visit

7 Duration of the visit
8 Advance A) To cover expenses on Hotel, Daily Allowance and
Conveyance (75%of the estimated expenditure)
(i) Hotel :
(ii) Daily Allowance:
(iii) Local Conveyance:
TotalAmount: Rs...............

B) Fare: (LOO%ofTicketcharges) Rs...............

Grand Total: Rs. .............

8 Amount of advance Rs............... ........ | - (in words

(Signature of the employee)

Dated:.......
Controlling officer

For use of Finance

Passed for advance payment of Rs.........1

Prepared by

Checked by

Sanctioning Authority
%
1
 Undertaking for application in another Organization (before joining)
Date:
To
The General Manager / HR
Dedicated Freight Corridor Corporation of India Ltd.
Pragati Maidan, New Delhi

Sir/Ma'am,
I hereby declare that prior to my joining DFCCIL, I have applied for the following
posts at following Organizations:

S.N Organizations Name Post Applied For

Name : __________________________
EMP ID : _________________________
Designation : _____________________
Date : ___________________________
Date Of Joining in
Corporate office : _________________
 DFCCIL
(FOR REGULAR EMPLOYEES)

CTG CLAIM FORM OF EMPLOYEES OF DFCCIL FIELD UNITS

1. Name of Official with Designation

2. Employee Code

3. Office order No. & Dated (copy attach)

4. Transferred From_________________To___________________

5. Last Pay Drawn

(Attach copy of pay-slip of month in which joined

at New station)
6. Date and Place of relieving from Old HQ

7. Date and Place of Joining at New HQ

8. Change of Residence (YES / NO)

9. Residential Address at Old Headquarter

10. Residential Address at New Headquarter

11. Travel Expenses on Transfer only from old HQ to

New HQ

12. Whether personal effects transferred by road

(*If yes, attach original bill/invoice clearly

indicating the distance & total weight of the

consignment/)

13. Amount Claimed

14. Whether personal effects were transported by rail

(*If yes, please attach original Railway

Receipt/invoice with weight)

15. Amount Claimed

16. Whether vehicle was transferred by Rail/Road

*Attach Original Invoice.

 *Also attach estimate freight invoice of

transportation of car

In passenger train from old station to new station

from

Railway for payment, if transported by Road.

17. If vehicle was transported by own propulsion

*Attach copy of state tax/toll-tax/petrol invoice

18. Total Amount Claimed under Transfer Benefits

(Provide Head wise break up)

CTG+ Transportation of HHE+Transport of Vehicle

The claim made by me as above is true to the best of my knowledge and belief. I am fully aware that if
something is found to be contrary then recoveries with penal interest (as declared by the company) will
be recovered from my salary/dues.

Date:- Signature of
Employee
For use by HR of Unit

Since DFCCIL has no policy of its own for transfer benefits, guidelines of MOR are followed.
Following payments are passed in favour of
Shri/Smt………………………………Designation……………………

A) CTG

B) Transportation of HHE

C) Transportation of Vehicle

CGM/Controlling Officer
 (For Deputationists)
Format for Claiming CTG on joining DFCCIL
1. Name of the Official :
Designation :
Employee Code :
2. Date and Place of Relieving: :
3. i) Date and Place of joining in DFCCIL :
ii) Whether deputationist/Regular :
Last Designation :
4. Last Pay + Grade Pay in Rlys. Or IDA Pay:
(Please attach a copy of LPC) Level :
Whether VPU availed :
(Please enclose details of Kit pass
& VPU used etc)
5. Whether carried a Car in VPU :
6. Whether the full Kit or bag & baggage has been shifted :
7. Whether Railway quarter has been vacated or not :
8. Whether personal effects were transported by Road :
9. If yes, please mention the distance and weight of luggage transported. :
(Also attach original cash receipts, duly verified.)
Amount Claimed for CTG :
Amount Claimed for Luggage :
Amount Claimed for transportation of Vehicle :
(Please enclose original cash/payment receipts thereof) :
___________________________________________________________________
The claim made by me as above is true to the best of my knowledge and belief. I am fully aware that if something is found
to be contrary then recoveries with penal interest (as declared by the company) will be recovered from my salary/dues.

Date:- Signature of Employee

For use by HR of Unit
The claim found is in order & as per rule. Submitted for forwarding to Corporate Office for payment please.
CPM/Controlling Officer
For use in Corporate Office/HR
Since DFCCIL has no policy of its own for transfer benefits, guidelines of MOR are followed.
Following payments are passed in favour of Shri/Smt………………………………Designation……………………

A) CTG
B) Transportation of HHE
C) Transportation of Vehicle (Dealing HR Officer)
JGM/HR

DGM/Finance-V
 Sub: Applftation for disbursement under welfare Rules

(Authority circular No. IIR/HW/3Ailelfare Fund Rules dated 30'04'2015)

l. Name of Employee
,. Employee Code
; Designation & Posting
4. Scale of Pay & Basic PaY

5. Name of Welfare ActivitY

6. Amount Admissible as Per rules
7. Proof of Claim
8. Total Amount Claimed
9. BankName
10. AccountNumber
11. IFSC Code
t2. MICRNo.
"c-
.Documentstobeattacheddufyverifiedbytheemployee.

Signature of emPloYee with date

Controlling Officer/Unit

DGM/IIR/CO
Sub :- Application for seeking permission for acquiring additional/Higher Education.
fo"k;%& vfrfjDr@mPp f’k{kk izkIr djus ds fy, vkosnu&i=A
Note: - Information in respect of all columns is compulsory for processing of application.
vkosnu ij dk;Zokgh fd;s tkus gsrq lHkh dkWyeksa dh lwpuk vfuok;Z gSA
13 Name & Designation.
deZpkjh dk uke vkSj in
2 Emp. Code.
deZpkjh dk dksM u0
3 Place of Posting.
rSukrh dk LFkku
4 Date of Appointment.
fu;qfDr dh frfFk
5 Regular/Deputationsis.
fu;fer@rnFkZ
6 Name of Course.
dkslZ dk uke
7 Duration of the Course.
dkslZ dh vof/k
8 Name of the Institution.
laLFkku dk uke
9 University/Board of which the institution is affiliated/associated.
fo’ofo|ky;@cksMZ ftls ;g laLFkku ekU;rk izkIr gSA lacfU/kr gSA
10 Whether the Board/University are recognized? If yes Name of the Authority
with which it is registered.
D;k ;g cksMZ@fo’ofo|ky; ekU;rk izkIr gS] ;fn gka rks izkf/kdj.k dk uke
crkb;s ftles ;g iathd`r gSA
11 Whether the course is correspondence or regular.
D;k ;g dkslZ i=kpkj ;k fu;fer gSA
12 Timing & Periodicity of the classes/lectures.
d{kk;sa@ysDpjksa dk le; ,oa vof/kA
13 Place where the classes/lectures would be held.
d{kkvks@
a ysDpjksa dk LFkku tgka fn;k tkuk gSA
14 Undertaking: I hereby declare that:-
eSa] ,rn}kjk opu nsrk@nsrh gwa fd
1. The above course will not hamper in discharging official duties.
mijksDr dkslZ ls esjs dk;kZy/khu dk;kZsa esa dksbZ ck/kk ugha vk,xhA
2. I will bear all expenses for acquiring the additional/higher qualification.
vfrfjDr@mPp f’k{kk izkIr djus dk [kpkZ esjs }kjk ogu gksxkA
3. I will avail leave as may be due for pursuit of the course. This however, in
no way binds the company to grant leave to me.
eSa dkslZ ds vuqlj.k ds ns; NqfV~V;ka ywx
a k@ywx
a hA ftlds fy, eq>s NqV~Vh
nsus gsrq daiuh ck/; ugha gSA
4. Permission to pursue the course for acquiring *additional higher
qualification will not be a ban to my transferability.
vfrfjDr@mPp f’k{kk dkslZ dks tkjh j[kus dh vkKk esjs LFkkukarj.k esa dksbZ
ck/kk ugh gksxhA

Encl:- 1. Photocopy of prospectus (Self attested).

layXu%& fooj.k if=dk dh izfr ¼Lo;a [Link]½

Signature fo the employee ………………………….

deZpkjh ds gLrk{kj
 &2&

(Certificate from the Controlling Officer/Project Incharge)

¼fu;a=.k vf/kdkjh@ifj;kstuk izHkkjh ls izek.k&i=½

Shri/Ms. ……………………………………………………………………may/may not be allowed to join the above mentioned course.

He can/cannot be spared to attend the course without affecting the office work. Jh --------------------------------------------------- dks

mijksDr dkslZ ds fy, vuqefr nh tkrh gS@ugha nh tkrh gSA mUgsa dk;kZy; ds dkedkt esa fcuk ck/kk ds dkslZ esa mifLFkr

gksus ds fy, dk;ZeqDr fd;k tk ldrk gS@ ugha fd;k tk ldrk gSA

Signature of Controlling Officer

fu;a=d vf/kdkjh ds gLrk{kj
Name & Desig. :-
uke vkSj in

Project/Functional Head
Ikfj;kstuk@dk;Z izeq[k

(FOR USE IN HR. CORPORATE OFFICE)

¼,pvkj ds fy,] dkWiksZjsV vkWfQl½

Jh@lqJh ------------------------------------------------- }kjk nh xbZ lwpuk dh tkap@laoh{kk dh xbZ vkSj bUgsa lgh ik;k x;kA
vfrfjDr@mPp f’k{kk --------------------------------------------------- dks i=kpkj }kjk tkjh j[kus ds fy, vuqeksnu gsrq izLrqr gSA

lgk;d izca/kd@,pvkj

la;qDr egkizca/kd@,pvkj

lewg egkizca/kd@,pvkj&II
Sub: Forwarding of Applications/issue of “No Objection Certificate” for external
employment.

 Eligibility: Regular employees of DFCCIL

 Application will not be forwarded, where an amployee is under suspension or facing deparmental
proceedings or prosecution in a court.
 Norms:
Length of service Forwarding of application/issue of NOC
Up to 3 years service from the date of appointment/ 2 years 4 applications/NOC in a Calender year
from the date of promotion
1. Purpose of application Forwarding of Application of “No Objection Certificate” for external employment
2. [Link] No. 3. Name of the
employee
4. Designation 5. Place of Posting
6. Contact No.(M) 7. Email ID
8. Regular Grade Date from which working in grade (IDA)
9. Date of Appointment. 10. status Regular/ Deputationist
11 Date of promotion, if any
12 Whether eligible to apply for the
post
13. Whether under suspension or facing departmental Yes or No
proceedings/prosecution in a court
14. No. of application forwarded /NOC issued during the current Calender year
15 Name and address of the organistion where application is to be forwarded
16 Post applied for 17 Last date for submission of application
Delete whichever is not applicable:-
Encl: 1. Copy of Notification/advertisement
2. D&AR from Project/Functional head.
(Please indicate the current status of D&AR case pending, if any)
Signature of the employee.............................
Remarks of Functional Head /Project Head

Signature of the controlling officer..........................

Name & Designation...........................................

Forwarded to HR, Corporate Office:-

1. Approval is sought subject to condition that :-
1) If selected, employee has to resign and join.
2) D&A and Vigilance clearance.
2. Competent Authority for approval.

AM/HR
JGM/HR

GM/HR

Director/Infra

MD
Eqq: cre+e vrw *,d * ftS sr+rqfr vqrur .rt
Sub: No Objection Certificate for obtaining Passport.

qFid1-ata i)+ffi'anr,r\qrf < ii )vlerlarlcsqrztr iii )w arrq'r{*Aq}ah:lsftrr$f ltaEfrYh-<61;u ) +ri"rrtsit

Notes for guidance:- i) To be filled by the Employee ii) Strikeout whichever is not applicabte iii) Attaclr tri't'r
passport size colored photograph with while background Employees who are attracted with any provision of
Sec. attached ofthe pr 11 act, 1967 cannot make application tor issue of NOC.

1 q,{qrft*s riwr
Employee C!49 Xg
2 erffiq,rrrq
Name of thB Emp&ygq
J
qfirc
Desisrration
4 frrrfr(ffid/qfttrs)
Status (Regul arlDeputati on) ,

5 furrlqfrqrqrc
Father's,lHusband Name
6 +Erfd i. qdg-+n erri6
Mobile No. & Email Id
7 qqftrFr
Date of Birth
8 ffinetr$q€it*.rdrrn q-6ur Efi td"rtr

Date of Joinine DFCCIL

9 **crqftnfrrerfr
Place of Postine
l0 ft-o,drqrs+ef+rq (vfrUe.+)

qrq+8{i@r cht tdtq

PassportNo. Date of lssue

*-ri or €n-{
Date of Expiry Place oflssue

ll qRsRffifiq{t*, F+ *ii
If on deoutation. fill
qd {irrarE,t {rq
Name of parent organization.

elilFfgfft q qrdFrR lrtrr 6Td 4'r kftsr

Date ofjoining on deputation

W €rT-d{[Link] qfirq
Post and address of the parent orgattization.
t2 dqun Declaration :-
fi gqrfrril u-rm / qlfr E fu n+ ql-q+8 erfuFcc 1967 * {ds 6(2) * sr{e{r{i +} q-q ftqr t eft srqrfum a*{(r /
fu {6qrl-d R t+ftslE-drfr ?t
"{frE
I certify that I have read the provisions of Section 6(2) of thc Passporl Act,196l and cerlif,r'V tllilt
these are not attracted in my case.
gc'q: (i) qrefr: erqnlAsbr.n (ii) ffiwuvl€fivfr
Encl: (i) Two passport size photographs; (ii) Photocopy of previotts p:rssport (in case of reneu'itl of
passport).

fui6. sdqrt 8n

Date: EmPloYee Signature

Signature of Coltrollir rg ()Uic:trr
fr{iTfi3rffi*'rrmsfl
Na-me c\ Desig.
arqst{qE

qrrsr eFrcTFt 6rft-c 6-lqidq

t,_,.-L-
* e-*tr t{

qlqm.E 3flqfr yqTq!-{ srtt *r} t frs ns=r 3{h 3rdcr q.i sd+RT fi*n{l :+.{'i--.+ vr.a d x+r t (rs)r wn€f++ :r11aa ;;
<
ftqy<att

gorqoqdtrfi' (rfi{R

g rflmilro/(tfiTR
"q+a
 Option for Fixation of pay on Promotion

In terms of office order no. _________________________________________

dated _______________, I have been promoted from ____________ as _____________
w.e.f. ____________ in IDA pay scale _______________________ And resumed the
charge of the post on ________________________ I hereby opt for fixation of pay as
marked under;

(a) From the date of promotion (i.e. date of assumption of charge)

(b) From the date of increment in the lower scale.

I hereby declare that the above ticked option exercised by me is final.

Signature: ……………………….
Name: ……………………………
Designation: ……………………
Emp. ID.: ……………………….
Date: …………………………….

The action regarding assumption of charge of the official in the higher post has
been initiated on SAP.

Concerned HR officer (unit/corporate office)

Controlling Officer (Unit/Corporate Office)

JGM/HR/CO
 Under taking for Rent Reasonability
This is to certify that rent asked by the owner of premises “Address ______________
______________________________________________________________________” rent
is Rs. __________________________ per month and this is reasonable.

Signature : ________________________

Name : ________________________

Designation : ________________________

Date : ________________________
 Date :

Consent Letter for Self lease

To,
General Manager (Co.)
DFCCIL
_____________________.

I hereby give my consent to give my house to DFCCIL on self-lease from

_____________ to _____________. The lease value of the house shall be
Rs._____________ per month over this period. The address of the house is as
under:-

Address : ______________________________

______________________________

______________________________

______________________________

Signature : ________________________
Name : ________________________
Designation : ________________________
Date : ________________________
 अनल
ु ग्‍नक-'क' Annexure-A

मनोरं जन‍भत्‍
ता‍वा स‍ स‍ ंधंत त‍राराप क‍का‍रारसषण
Performa for submission of claim related to Entertainment Allowance
व षय:‍मनोरं जन‍भत्‍
ता‍वा ा‍ामाा ार ‍
Sub: Claim for entertainment allowance (Month wise)‍
माा‍Month-- व त्‍
तीय‍ ष‍Financial Year- 20___

बधल‍दवनांक‍Date of राशि‍ Balance

क्र .ं [Link]. बधल‍ .ं Bill No.
Bill Amount‍

कुल‍राशि/Total Amount‍

1. मैं घोषणा करता हूं कक मैने सभी मनोरूं जन बिलों को वित्तीय व िषक के तूंत ंिूं तेले िषक
तक तपनी तभभरक्षा में रखा है । I hereby declare that all the bills entertainment allowance
mentioned herewith have been preserved and kept in custody till end of the financial year
plus next one year.
2. मनोरूं जन भत्ता हे तद वािे कग ेर राभम मेरे ्‍त पा्रतता के तनस
द ार है । ममाह ंिूं वित्तीय व िषक
िार)Amount of claim of entertainment allowance above is as per my entitlement (Month
Wise and Financial Year Wise)

ास्‍
ताक्षर‍Signature: -
नाम‍Name:
कवनाम‍DESIGNATION:
कमचारी‍ ख्
ं ‍या‍Employee ID-
स्‍टसिन/कायालय‍Station/office
रारस्‍तत
ु ‍करनस‍कत‍थतत ‍Date submission-
Sub: Reimbursement of perks and allowances issued vide Circular
No.23/2019 dated 09.09.2019
Ref : (1) Joint Procedure Order No. HQ/HR/Perks & allowances/Pt. 1
(2) CGM/ADI NO. DFCCIL/HR/Misc./09/2019 dated 31.10.2019

Subject & Reference above, please arrange to sanction and payment of the following
perks and allowances.

HARD & SOFT FURNISHING

Total Self-
Gross
Sr. No. Bill No. Date GST amount ceiling Balance
Amount
claim limit

TOTAL AMOUNT CLAIM

Signature :_________________________

Name :____________________________

Designation : _______________________

Emp. ID : _________________________

PM/HR

GM (Co.)
 Annexure

Emp. Code……………Name…………………………Design…….………Place of posting…..….…

Sub: Identification of key Result Areas (KRAs) for the financial year ______________.

S. Key Result Areas Whether MoU Weightage (%) Target Date of

No. item (Yes/No) completion

(1) (2) (3) (4) (5)

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

TOTAL 100

Signature of Employee Signature of Reporting Officer

Date : Name : …………………………………

Designation:………………………….

Date:……………………………………
 ƒ—ƒŽ‘ˆ  

)2501R,

6WDWHPHQWRILPPRYDEOHSURSHUW\RQILUVWDSSRLQWPHQW
DVRQWKHVW'HFHPEHU
HJ/DQGV+RXVH6KRSV2WKHU%XLOGLQJVHWF 
6O 'HVFULSWLRQ 3UHFLVHORFDWLRQ 1DPHRI $UHDRIODQG LQ 1DWXUHRIODQG ([WHQWRI ,IQRWLQRZQ
1R  RISURSHUW\  'LVWULFW'LYLVLRQ7DOXN FDVHRIODQG LQFDVHRI LQWHUHVW  QDPHVWDWHLQ
DQG9LOODJHLQZKLFKWKH DQGEXLOGLQJV  ODQGHG ZKRVHQDPHKHOG
SURSHUW\LVVLWXDWHGDQG SURSHUW\  DQGKLVKHU
DOVRLWVGLVWLQFWLYH UHODWLRQVKLSLIDQ\
QXPEHUHWF  WRWKH*RYHUQPHQW
VHUYDQW 

  
        


     


'DWHRI +RZDFTXLUHG ZKHWKHUE\SXUFKDVH 9DOXHRI 3DUWLFXODUV 7RWDODQQXDO 5HPDUNV 

DFTXLVLWLRQ  PRUWJDJHOHDVHLQKHULWDQFHJLIWRU WKH RIVDQFWLRQ LQFRPHIURP
RWKHUZLVH DQGQDPHZLWKGHWDLOVRI SURSHUW\ RISUHVFULEHG WKHSURSHUW\ 
SHUVRQSHUVRQVIURPZKRPDFTXLUHG VHH1RWH DXWKRULW\LI
DGGUHVVDQGFRQQHFWLRQRIWKHHPSOR\HHLI EHORZ  DQ\ 
DQ\ZLWKWKHSHUVRQSHUVRQVFRQFHUQHG 
3OHDVHVHH1RWHEHORZ 


         


    


 

'DWH««««««««6LJQDWXUH«««««««

1RWH

 )RUSXUSRVHRI&ROXPQWKHWHUPOHDVHZRXOGPHDQDOHDVHRILPPRYDEOH
SURSHUW\IURP\HDUWR\HDURUIRUDQ\WHUPH[FHHGLQJRQH\HDURUUHVHUYLQJD
 ƒ‰‡͹ͷ

 ƒ—ƒŽ‘ˆ  

\HDUO\ UHQW :KHUH KRZHYHU WKH OHDVH RI LPPRYDEOH SURSHUW\ LV REWDLQHG
IURP D SHUVRQ KDYLQJ RIILFLDO GHDOLQJV ZLWK WKH HPSOR\HH VXFK D OHDVH
VKRXOG EH VKRZQ LQ WKLV &ROXPQ LUUHVSHFWLYH RI WKH WHUP RI WKH OHDVH
ZKHWKHULWLVVKRUWWHUPRUORQJWHUPDQGWKHSHULRGLFLW\RIWKHSD\PHQWRI
UHQW
 ,Q&ROXPQVKRXOGEHVKRZQ
D ZKHUHWKH SURSHUW\ KDV EHHQ DFTXLUHG E\ SXUFKDVH PRUWJDJH RU OHDVH
WKHSULFHRUSUHPLXPSDLGIRUVXFKDFTXLVLWLRQ
E ZKHUHLWKDVEHHQDFTXLUHGE\OHDVHWKHWRWDODQQXDOUHQWWKHUHRIDOVR
DQG
F ZKHUH WKH DFTXLVLWLRQ LV E\ LQKHULWDQFH JLIW RU H[FKDQJH WKH
DSSUR[LPDWHYDOXHRIWKHSURSHUW\VRDFTXLUHG

 

 ƒ‰‡͹͸

 ƒ—ƒŽ‘ˆ  

)2501R,,

6WDWHPHQWRIOLTXLGDVVHWVRQILUVWDSSRLQWPHQW
DVRQWKHVW'HFHPEHU
 &DVKDQG%DQNEDODQFHH[FHHGLQJPRQWKV·HPROXPHQWV

  'HSRVLWV ORDQV DGYDQFHV DQG LQYHVWPHQWV VXFK DV VKDUHV VHFXULWLHV

GHEHQWXUHVHWF 

6O 'HVFULSWLRQ  1DPH $GGUHVV $PRXQW  ,IQRWLQRZQQDPHQDPH $QQXDO 5HPDUNV 

1R  RI&RPSDQ\ DQGDGGUHVVRISHUVRQLQ LQFRPH
%DQNHWF  ZKRVHQDPHKHOGDQG 
GHULYHG
KLVKHUUHODWLRQVKLSZLWK
WKH*RYHUQPHQWVHUYDQW

           

      








 

'DWH««««««««

6LJQDWXUH««««««««««

1RWH

 ,Q FROXPQ  SDUWLFXODUV UHJDUGLQJ VDQFWLRQV REWDLQHG RU UHSRUW PDGH LQ
UHVSHFWRIWKHYDULRXVWUDQVDFWLRQVPD\EHJLYHQ

 7KH WHUP HPROXPHQWV PHDQV WKH SD\ DQG DOORZDQFHV UHFHLYHG E\ WKH
HPSOR\HH

 

 ƒ‰‡͹͹

 ƒ—ƒŽ‘ˆ  

)2501R,,,

6WDWHPHQWRIPRYDEOHSURSHUW\RQILUVWDSSRLQWPHQW
DVRQWKHVW'HFHPEHU

6O 'HVFULSWLRQ 3ULFHRUYDOXHDWWKHWLPHRI ,IQRWLQRZQQDPH +RZDFTXLUHG 5HPDUNV
1R RILWHPV DFTXLVLWLRQDQGRUWKHWRWDO QDPHDQGDGGUHVVRI ZLWK
SD\PHQWVPDGHXSWRWKH WKHSHUVRQLQZKRVH DSSUR[LPDWH
GDWHRIUHWXUQDVWKHFDVH QDPHDQGKLVKHU GDWHRI
PD\EHLQFDVHRIDUWLFOHV UHODWLRQVKLSZLWKWKH DFTXLVLWLRQ
SXUFKDVHGRQKLUHSXUFKDVH HPSOR\HH
RULQVWDOOPHQWEDVLV

     

     

'DWH«««««««    6LJQDWXUH««««««««

1RWH

 ,Q WKLV )RUP LQIRUPDWLRQ PD\ EH JLYHQ UHJDUGLQJ YDOXH RI LWHPV OLNH
MHZHOOHU\ VLOYHU  RWKHU SUHFLRXV PHWDOVVWRQHV 0RWRU &DUV
6FRRWHUV0RWRUF\FOHV UHIULJHUDWRUVDLUFRQGLWLRQHUV WHOHYLVLRQ VHWV DQG VXFK
RWKHUDUWLFOHV

 ,Q FROXPQ PD\ EH LQGLFDWHG ZKHWKHU WKH SURSHUW\ ZDV DFTXLUHG E\
SXUFKDVHLQKHULWDQFHJLIWRURWKHUZLVH

 

 ƒ‰‡͹ͺ

 ƒ—ƒŽ‘ˆ  

)25012,9

6WDWHPHQWRI3URYLGHQW)XQGDQG/LIH,QVXUDQFH3ROLF\
RQ)LUVW$SSRLQWPHQWDVRQWKHVW'HFHPEHU
6 3ROLF\ 1DPHRI 6XP $PRXQW 7\SHRI &ORVLQJ &RQWULEXWLRQ 7RWDO  5HPDUNV LI
1R  1RDQG ,QVXUDQFH LQVXUHG RI 3URYLGHQW EDODQFHDV PDGH WKHUHLVGLVSXWH
GDWHRI &RPSDQ\  GDWHRI DQQXDO )XQGV ODVW VXEVHTXHQWO\ UHJDUGLQJ
SROLF\ PDWXULW\  SUHPLXP  *3) UHSRUWHG FORVLQJEDODQFH
&3) E\WKH WKHILJXUHV
,QVXUDQFH $XGLW DFFRUGLQJWRWKH
3ROLFLHV  $FFRXQWV *RYHUQPHQW
DFFRXQW 2IILFHU VHUYDQWVKRXOG
1R  DORQJZLWK DOVREH
GDWHRI PHQWLRQHGLQ
VXFK WKLVFROXPQ 
EDODQFH 

         

         







'DWH«««««««      6LJQDWXUH««««««

 ƒ‰‡͹ͻ

 ƒ—ƒŽ‘ˆ  

)2501R9

6WDWHPHQWRI'HEWVDQG2WKHU/LDELOLWLHVRQ)LUVW
$SSRLQWPHQWDVRQVW'HFHPEHUBB

6O $PRXQW 1DPHDQGDGGUHVV 'DWHRI 'HWDLOVRI 5HPDUNV

1R RI&UHGLWRU LQFXUULQJ 7UDQVDFWLRQ
/LDELOLW\ 

     

     





'DWH««««««««     6LJQDWXUH«««««««««

1RWH  ,QGLYLGXDO LWHPV RI ORDQV QRW H[FHHGLQJ WKUHH PRQWKV HPROXPHQWV
QHHGQRWEHLQFOXGHG

 

 ƒ‰‡ͺͲ

 ƒ—ƒŽ‘ˆ  

$QQH[XUH9,,

6WDWHPHQWRI$QQXDO,PPRYDEOH3URSHUW\5HWXUQIRUWKH\HDU«

 1DPH

 'HVLJQDWLRQ

 'DWHRIDSSRLQWPHQW

 3D\6FDOH

1DPH RI 1DPH DQG GHWDLOV 3UHVH ,I QRW LQ +RZ DFTXLUHG $QQXDO 5HPD
GLVWULFW RISURSHUW\ QW RZQ QDPH :KHWKHU E\ ,QFRPH UNV
VXE 9DOXH VWDWH LQ SXUFKDVH OHDVH IURP
'LYLVLRQ +RXVLQJ /DQGV ZKRVH QDPH PRUWJDJH WKH
7DOXN DQG KHOG DQG LQKHULWDQFHJLIWRU SURSHUW\
DQG RWKHU KLVKHU RWKHUZLVH ZLWK
9LOODJH LQ EXLOGLQJV UHODWLRQVKLS GDWHRI
ZKLFK WR WKH DFTXLVLWLRQ DQG
SURSHUW\ HPSOR\HH QDPHZLWKGHWDLOV
LV RI SHUVRQV IURP
VLWXDWHG ZKRPDFTXLUHG
       
       

   

6LJQDWXUHZLWKGDWH«««««««««««

1RWH

 ,QDSSOLFDEOHFODXVHWREHVWUXFNRXW
 ,Q FDVH ZKHUH LW LV QRW SRVVLEOH WR DVVHVV WKH YDOXH DFFXUDWHO\ WKH
DSSUR[LPDWHYDOXHLQUHODWLRQWRSUHVHQWFRQGLWLRQVPD\EHLQGLFDWHG
 7KLV IRUP LV UHTXLUHGWR EH ILOOHG LQ DQG VXEPLWWHG E\HPSOR\HHV LQ $0
DQG DERYH LQ -DQXDU\ HYHU\ \HDU JLYLQJ SDUWLFXODUV RI DOO LPPRYDEOH
SURSHUW\RZQHGDFTXLUHGRULQKHULWHGE\KLPRUKHOGE\KLPRQOHDVHRU
PRUWJDJHHLWKHULQKLVRZQQDPHRULQWKHQDPHRIDQ\PHPEHUVRIKLV
IDPLO\RULQWKHQDPHRIDQ\RWKHUSHUVRQ

 ƒ‰‡ͺͳ

 Dedicated Freight Corridor Corporation of India Limited
(A Govt. of India Enterprises)
5th Floor, Pragati Maidan Metro Station Building Complex,
New Delhi - 110001

No Dues Certificate
(To be furnished in case of separation of employees on account of transfer/
superannuation/ retirement/ resignation/ termination from service/
Repatriation/proceeding on deputation to other departments).

Shri./Smt./Ms.…………………………………………………………………………….(
Designation)……………………………. (Emp. Code No.)…………………….. (Place
of posting)* is being relieved on account of Transfer/retirement/
resignation/ repatriation/deputation to other departments w.e.f.
…………………....

2. All Department concerned are advised to issue “No dues/demand

certificate” in respect of the above mentioned employee within 7 days.

*Strike out whichever is not applicable.

Date: (Signatures of the official dealing HR)

Encl.: Four

Note: Please ensure that each item/column must be specifically filled in with the
words “NIL”/NOT APPLICABLE” and should have the signatures of the Sectional
Head.
 INFORMATION/ DECLARATION FROM THE
EMPLOYEE/DEPUTATIONISTS

I hereby declare that:______________________________________________________

1 Details of bond signed on account of training

(not applicable in case of transfer).

(Not applicable in case of deputationists)

2 I stood surety for other DFCCIL employees for

obtaining House Building Advance;
Multipurpose advance; Vehicle advance;
Other advance; executing bond for training,
etc. The details of which are-

(Not applicable in case of deputationists)

3 Permanent Address

4 Communication Address (Post Separation)

5 Contact No’s (Personal & Official): Landline:

Mobile:

E-Mail ID:

6. Any other details

(Signature/Designation of the Employee)

 No Dues Certificate

Name of Emp.: ……………………… Emp. No.: …………………….

Signature
Finance Department- Book Section
of Section
(JGM/F-II)
In-charge
1 Conveyance Advance, if any, if yes, please Amount Rs.
indicate outstanding amount along with
interest. Interest Rs.

(Not applicable in case of deputationists) Total Rs.

2 Multipurpose, if any, if yes, please indicate Amount Rs.

outstanding amount along with interest.
Interest Rs.
(Not applicable in case of deputationists)
Total Rs.

3 Tour advance outstanding, if any

(including foreign tours)

4 LTC Advance outstanding, if any

(Not applicable in case of deputationists)

5 Medical Advance outstanding, if any

6 Any other outstanding amount standing

against the outgoing incumbent including
company assets etc..

7 Whether Lease Security has been refunded

by the employee?

Finance-Bills & Books Section:

(JGM/F-II – AGM/F-III)

1. Credit card as well as clearing any private

payments by the employee thereon

2. Any other dues/ amount recoverable

3. Whether Employee has cleared his imprest

outstanding, if any.

4. Books Section
 S & T Department

1. Data Card / SIM Card

2. Telephone / Mobile Instrument

3. Brief Case

3. Any other items dues.

IT Department

1. Laptop

2. Computer Set

3. Printer / Calculator etc.

4. Hard Disk Drive (HDD)
5. Any other Hardware/ Software etc.

6. Any other dues if any.

Administration Department
Whether identity card, office vehicle and
other general articles issued have been
1. received back? If not, details thereof and
amount to be recovered may be indicated.
2. Any other dues, if any.

Library
Whether Books issued have been received
1. back? If not, details thereof and amount to
be recovered may be indicated.

2. Any other dues, if any.

Human Resource Department

Applicable to employees having Company
Leased Accommodation – whether “No
1. Dues” and ‘vacation’ certificate from, the
landlord, has been received, if not, details
thereof.
Details reg. recovery of bond amount
executed on account of fresh appointment,
2. if any.
(Not applicable in case of deputationists)
Whether any disciplinary action is
pending/ contemplated against the
3. employee
(Not applicable in case of deputationists)
Whether lease facility has been
4.
withdrawn?

5. LTC availed/Next LTC Due

 No Dues Certificate
Name of Emp.: ……………………… Emp. No.: …………………….

6. Hard & soft furnishing

7. RH/CL availed during year 20___

Balance

8. Medical Reimbursement claim

availed (80%) amount for
Dependent Parents.
 I

Eligibility: Regular employees of DFCCIL

Norms:

( YY-MM-DD)

Minimum period of 3 years' regular service from the date of appointment

1. Emp. Code No. 2. I Name of the employee
3 Designation 4. I Place of Postins
5 Grade & Basic pav
6 Contact No.(M) 7. I Email to
R Status Absorbed/Regu la r
9 Date of Appointment. | 10. I status
11 Date of application for resignation

L2 Date of receipt of resignation in controlling Unit

13 Reasons of resignation
L4 NOTICE PERIOD OF 03 MONTHS
(a) Date of completion of notice period
(b) Balance days of notice period g
(c) Amount of balance notice period deposited / adjusted from balance leave Yes or No

15 BOND
(a) Whether completed 03 years of regular service Yes or No
(b) Whether employee has agreed to deposit proportionate residual bond amount Yes or No

(c) For transfer of bond to other PSU/ Govt Undertaking

(i) Consent of new organisation (PSU's/Govt Undertaking) has been taken Yes or No
(ii)Whether employee has submitted undertaking to serve for remaining Yes or No
period in new company
15 Details of dues pending

Encl: D&AR from Project/Functional head.

(elease indicate the current status of D&AR case pending, if any)
The employee is free from D&AR angle Signature of the emp1oyee................

Signature of the controlling officer

Name & Designation