Affidavit Format For Medical Reimbursement

Affidavit Format For Medical Reimbursement
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 ____

                                                                                                                                                                           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

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes:

<a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>

* Copy This Password *

* Type Or Paste Password Here *