APPLICATION UNDER SECTION 16 OF THE ACT IN RESPECT OF CLAIMS FOR REFUND OF FARES OR PART THEREOF OR FOR REFUND OF ANY FREIGHT PAID IN RESPECT OF ANIMALS OR GOODS ENTRUSTED TO A RAILWAY ADMINISTRATION TO BE CARRIED BY RAILWAY.
[SEE RULE 5 OF THE RAILWAY CLAIMS TRIBUNAL (PROCEDURE) RULES, 1989].
PART I
To,
The Registrar,
Railway Claims Tribunal,
____________________Bench
____________________
Title of the case:
PART II
INDEX
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Description of documents attached |
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Signature of the Applicant
For use in Tribunal’s Office.
Date of filing
or
Date of Receipt by post
Registration No.
Signature for Registrar.
PART III
IN THE RAILWAY CLAIMS TRIBUNAL
___________ Bench
___________________________Applicant
VERSUS
___________________________Respondent
1. Particulars of the Applicant:
a. Name and address:
2. Particulars of the respondent/respondents;
3. Value of claim and details of application fee
a.Value of claims
b.Details of application fee;
4. Particulars of Bank Draft/Postal Order in respect of Application Fee:
a. Name and address of the Bank on which the draft is drawn;
b. Demand Draft No. and the Branch at which payable.
5. Or
a.Number of Indian Postal Order (s)
b.Name of issuing Post Office
c.Date of issue of Postal Order(s)
d. Post Office at which payable.
6. Full particulars of payment of fare/freight.
a.Claim for refund of freight.
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Date of Booking |
[Railway Receipt or Parcel Way Bill] |
Station |
Description of consignment |
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From |
To |
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1 |
2 |
3 |
4 |
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Freight paid |
Amount Refund of Claims |
Money Receipt/Credit Note or other payment particulars |
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5 |
6 |
7 |
(ii) Claim for refund of fare
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Date of journey |
Train No. |
Class of Travel |
Class actually travelled. |
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1 |
2 |
3 |
4 |
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Ticket or Ticket Deposit Receipt/Excess Fare Ticket etc Guards or Conductors, Certificate
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Fare paid Rs. |
Refund Claimed Rs. |
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5 |
6 |
7 |
A. Date on which notice served in Railway Administration under Section 78-B of Indian Railways Act, 1890 (in respect of claims for refund of freight) - Attach Proof
i. Facts of the case: (Give here a concise statement of facts in a chronological order, each paragraph containing as nearly as possible, a separate issue, fact or otherwise)
ii. Nature of relief sought; and Grounds of relief.
B. Matters not previously filed or pending with any other Court. (State whether the applicant had previously field any claim, writ petition or suit regarding the matter in respect of which the present application has been made).
a. In case the applicants had previously filed any claims, application, writ petition or suit, indicate the stage at which it is pending, and if decided, attach a certified copy of the order.
C. Jurisdiction of the Bench (indicate the facts on the basis of which the Bench to which application is made, has the jurisdiction).
D. List of enclosures:
1.
2.
3.
4.
5.
Verification
I, _______________________________ (Name of the applicant)
S/o, D/o, W/o, ___________________________ age__________ resident of __________________________________________ do hereby verify that the contents of paragraphs ______ to ______ are true to my personal knowledge, and paragraphs ______ to ______ are believed to be true to the best of my knowledge or the legal advice given to me, and that I have not suppressed any material fact.
Date:
Place:
Signature of the applicant
Full address:
