Affidavit Format 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 ____/- as towards Hospital expenditure.

3- That I further state that I am entitled for medical reimbursement from the ____.

4- That further state that I am drawing my ____ vide ____

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 ____