Form VI Application Form for a Certificate of Being Physically Challenged Persons To The Competent Authority, __________________________, Sir, I request that a certificate of being handicapped is being issued in my favor . The grounds of my claim and other particulars are given as below : 1. Name of the Applicant __________________________________________________ 2. Father's Name ___________________________________________________ 3. Place of Residence ___________________________________________________ i. Village/ Mohalla ___________________________________________________ ii. Tehsil ____________________________________________________ iii. District ____________________________________________________ 4. Whether the applicant is a permanent residence of the state _____________________________________________ 5. The infirmity on the basis of which the benefit is claimed ____________________________________________ 6. Total annual Income ( from all Sources) _____________________________________________ 7.. Date of Submission ______________________________________ I solemnly declare that above entries are true to my knowledge. Signature of the Applicant (For Use in Office or Competent Authority) Application received on ______________ and entered in the Register under No.______________ Competent Authority With Seal
