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 ____
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 ____