APPLICATION FORM FOR FINANCIAL ASSISTANCE FOR MEDICAL TREATMENT OF THE AGED (To be submitted through the District Social Welfare officer concerned) Incomplete application(s) received after the stipulated date will not be entertained Last of submission of the application is _______________________________________ 1. Name of the applicant ( in block letter) ___________________________________ 2. Certificate of the age (attested copy to be attached) If this certificate is not available, approximate age as on the 1st January of applying year duly certified by the Medical Officer may be furnished. 3. Name of father/husband/wife _____________________________________________ 4. Is the father/husband alive _____________________________________________ 5. Present address _____________________________________________ 6. Permanent address _____________________________________________ 7. Whether in receipt of any other assistance from government, if so indicate the amount 8. Whether belonging to SC/ST/OBC or not? If reply is in the affirmative, (please attach certificate) 9. Name and address of two responsible persons well known to the applicant who could certify the correctness of his/her statement 1. _____________________________________________ 2. _____________________________________________ 10. Whether permanently or partially disabled. Name/Nature of disability 11. Annual income from all sources 12. Are you more than 25 years domiciled in Meghalaya Date Signature / Thumb Impression of the applicant Place DECLARATION OF INCOME Certified that to the best of my knowledge the annual income from all sources of Shri./ Smt. ______________________________________ son/daughter of Shri / Smt. _____________________________ Is Rupees _____________________________ _____________________________ per annum Place : Signature of the Issuing Authority Date: Full name ______________________ Designation _____________________ Seal __________________________ Address in full ________________________ This certificate may be signed by the Local MLA/MDC/ Local Headman (CERTIFICATE TO BE SIGNED BY THE MEDICAL OFFICER) I Director of Medical & Health Office/Medical Officer ________________________ have examined Shri/Smt.________________________ aged about _________________ and certify that she/he suffering from ________________________ and advise from Medical treatment/purchase of Medicines amounting to Rs. ________________________ ( Rupees ___________________________________________________) Approximately Place : Signature of the Issuing Authority Date: Full name_____________________ Designation _____________________ Seal _________________________
