CHIEF MINISTER'S RELIEF FUND Needy and distressed applicants seeking assistance from the Chief Minister's Relief Fund are required to apply in the prescribed application form reproduced below: Sample Application Form: FROM OF APPLICATION FOR ASSISTANCE FROM CHIEF MINISTER'S RELIEF FUND OF ORISSA ******* PART A 1) a) Name of the applicant : b) Father's/Husband/Guardian's Name: 2) Address: Village: Ward No.: P.O.: P.S.: Tahasil: Sub-Division: District: 3) Occupation: 4) Annual Income: Govt. Service Source of Business Source of Lands Any other Sources Total Income 5) Purpose: 6) Required Amount 7) Has he/she received any assistance from this fund earlier ? 8) If yes, amount & purpose Signature of the Applicant Dt........ 9) Recommendation of the Tahasildar/Sub-Collector (Concerned officer should know correctly the fact mentioned at Column No.4) a) Details of income of the Applicant : i)From Agriculture : ii)From Salary : iii)From other sources : iv) Total : a) Financial condition of near relatives : b) Is prayer of the Applicant acceptable : c) Remarks : Signature of Tahasildar/Sub-Collector (With Seal) 10) Recommendation of Medical Officer. a) Disease : b) What type of treatment required : c) Cost of the Medicine : d) Appratus : e) Any other expenditure : f) Place of treatment : i)The reason for recommending treatment outside the State : ii) Is such treatment available in Orissa?: Signature of Medical Officer. (With seal) Counter Signature of Head of the Institute (With seal) 11) Recommendation of M.L.A./M.P./Minister : Signature of M.L.A./M.P./MINISTER (With Seal)
