REFUND OF CLAIMS/OVER DEDUCTION FORM

Affix two passport
photographs with your
name @ the back.

SURNAME……………………………………

OTHER NAMES……………………………….......................

ORACLE NO……………………..…………...

MEMBERSHIP NO …………………………........................

MDA ADDRESS ………………….……..………..........................................................................................................

OFFICE/SCHOOL …………………………………………………………………………..………………..................

TYPE OF ASSET PROCURED …………………………..…………………………………………………………..……..…

PERIOD OF PROCUREMENT …………………………..…………………………………………………………..……....

VALUE …………………………..………………..…………………… AMOUNT DEDUCTED…………………………..

REFUNDABLE AMOUNT/CLAIM ………………………………………… PERIOD OF CLAIM………………………..…

NET PAY (attachment of recent payslip) ………….………………………………………………………………… (compulsory)

E-Mail ADDRESS ………………………………………………..…………………Tel No .……………………………………

I ……………………………………………………………………………………..hereby apply for immediate payment/ refund of the amount over deducted/ deducted from my salary as stated above.

FOR OFFICE USE ONLY

……………………………………                                                                                                 ……………….................……….
            Secretary                                                                                                                                                       Treasurer
                                                                                   ………………………………………
                                                                                                         President

Approved Not approved