Needy and distressed applicants seeking assistance from the Chief Minister's Relief Fund are required to apply in the prescribed application form reproduced below: 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 CHIEF MINISTER'S RELIEF FUND FORM OF APPLICATION FOR ASSISTANCE TO CHIEF MINISTER'S RELIEF FUND OF ORISSA Government of Orissa /-Rs. Rs. /- Rs. /- Rs. /- Rs. /- Published on National Portal of India (india.gov.in) Department of General Administrations 9) Recommendation of the Tahasildar/Sub- Collector(Concerned officer should know correctly the fact mentioned at Colum No.4) a) Details of income of the Applicant ii) From Salary : iii)From other sources : iv)Total : a) Financial condition of near relatives : b) Is prayer of the Applicant acceptable 5) Purpose 6) Required Amount 7) Has he/she received any assistance from this fund earlier ? Signature of the Applicant Date. Signature of Tahasildar/Sub-Collector (With seal) If yes, amount & purpose 8) i) From Agriculture : Yes No Yes No Rs. /- Rs. /- Rs. /- Rs. /- Rs. /- Rs. /- Rs. /- c) Remarks : Published on National Portal of India (india.gov.in) Signature of Medical Officer. (With seal) Counter Signature of Head of the Institute (With seal) Signature of M.L.A./M.P./MINISTER (With Seal) 11) Recommendation of M.L.A./M.P./Minister Recommendation of Medical Officer :- a) Disease : b) What type of treatment required d) Apparatus : f) Place of treatment : i) The reason for recommending treatment outside the State : ii) Is such treatment available in Orissa?: Yes No c) Cost of the Medicine : Rs. /- Rs. /-e) Any other expenditure Published on National Portal of India (india.gov.in)
