Form No.9 ANDAMAN AND NICOBAR ADMINISTRATION DIRECTORATE OF FISHERIES * * * * APPLICATION FORM FOR FINANCIAL ASSISTANCE FOR LOSS OF CRAFT AND GEAR WHILE FISHING AND DUE TO NATURAL CALAMITY 1. Name, Age, Father's name & address of the applicant : 2. Permanent Address : 3. Address for communication : 4. Details of fishing licence in case of fishermen for the last five year including current year : Year ANB ANF 5. Whether belongs to ST : Yes No 6. Place, date & time of loss of fishing craft / gear : 7. Whether the incident was reported to the Fisheries department / police within 2 days of the incident (produce copy of the report) : Yes No 8. Whether received any relief on the incident from any Govt. agency? If so details thereof 9. Name, father's name, address and Licence No. of fishermen who went for fishing with the applicant : 10. In the case of loss/ damage of fishing craft, furnish the following : (i) Registration No. : (ii) Year of construction : (iii) Length, Breadth & Depth : (iv) Make of craft ( mark the applicable item) : Wooden Fibre Steel (v) Whether motorized/ non-motorized if motorized : Brand Name of engine : H.P of Engine : Year of purchase : Cost (Rs.) : Whether any subsidy was granted by Fisheries Deptt. or any other agency, for purchase of craft/ engine and if so details thereof : 11. In case of loss/ damage of fishing gear, furnish the following (a) No. and type of gear : (b) Total dry weight of net lost (Kg) : (c) Cost (Rs.) (d) Whether issued on subsidy by the department : : 12. Details of any other item lost/ damage (please specify item with cost) : 13. Total loss sustained (Rs.) : Certified that the information furnished above is true to the best my knowledge and belief and I shall be personally responsible if any part of the information is found incorrect. Place : Date : Signature of Applicant Recommendation of the members of the respective Panchayati Raj Institution/Counsellor of Municipal Ward (with name, signature, seal and date) Certificate Certified that I know personally Shri...............S/o........ ...................R/o ............village is a marine fishermen by profession and to the best of my knowledge and belief, due to natural calamity / accident while fishing, he has lost / damaged fishing craft / gear. (Name, Signature and Seal) Panchayat / ward Place : Date : For Office Use Only 1.Date of receipt of application 2.Field verification report including detailed assessment of cost of fishing craft and gear lost (provide copy of assessment made immediately after reporting of the incident) and specific recommendation of the Officer In-charge (Use separate sheet incase the space provided is not sufficient) (Name, signature, date and seal) 3. Recommendation of Zonal Officer In-charge (Use separate sheet incase the space provided is not sufficient) (with name, signature, date and seal) For use in the Directorate of Fisheries
