APPLICATION FORMAT Financial assistance to Men of Letters and arts who are in indigent circumstances 1. Full Name & Address : 2. Permanent Residential Address : 3. Date of Birth : 4. Citizenship : 5. *Present Occupation if any and : Amount of present income from all Sources put together *Employment and Income details : of Spouse 6. Number of persons wholly dependent on the applicant : ---------------------------------------------------------------------------------------------------- Name Age Relationship Occupation ---------------------------------------------------------------------------------------------------- 7. Immovable Property if any owned : in name of self or the Dependant member 8. Particulars of contributions made : to the field of culture 9. Particulars of awards, recognition or : destination received from Govt. on any prominent literary of arts society. (Relevant certificates to be attached) 10. Whether the applicant is in receipt : of any other rent or award from Government of India/State Govt., and if so details 1/2 11. Any other relevant information (Including details of Bank Account, if any) : 12. Name of the three references from the relevant field or specialization not directly related to the applicant : (SIGNATURE OF THE APPLICANT) Place: Date : *Age and Income Certificates in English or in Hindi duly certified by Gazetted Officer/ Councilor / MLA / MP. 2/2
