GCPP.-lSS/l2-2,OOO Cps. (04)-28-7-2005. - FORM-I ~ [See Rule 5(1)] APPLICATION FOR THE PERUNTHALAIVAR KARMAVEERAR KAMARAJ SCHE:ME FOR FINANCIAL ASSISTANCE TOWARDS FUNERAL EXPENSES OF DISABLED PERSONS .. WHO ARE IN RECEIPT OF THE FINANCIAL AND OTHER ASSISTANCE FROM SOCIAL WELFARE DEPARTMENT IN THE UNION TBRRITORY OF PONDICHERR Y PART-I (pARDCULARS OF THE DECEASED) N~me of the deceased diSabled person Name of the father/husband of the deceased2. Pension No. (Enclose the Original Card issued by the Department) 3. I Place and addr~s where death occured4- Cause of death5. Date of death (Copy of the burialfcremation order is&ued by the competent authority) 6. which financial assistance7 Month upto rec:eived was PART-II (pARTICULARS OF THE APPLICANT) Name of the applicant "',-;~ Falher"sfHusband"s name Relatiol1~hip with the deceased (Enclose any proof such as ration card !birth certificatQi marriage ~rtiricate'election photo identity card to establish 'the relationship) : 3- rites and funeral.Place where ~rronned 1a~t4, were 5. Date of funeral 6. Details deceased of .the spouse/sons/daughters of the Name Sl.No. Age Relationship Address1.2 Whether belongs to SC/ST Whether the applicant has applied forI obtained any assistance from any other source for the same purpose? If so, please fUrnish the details : I husband/wifefsonfdaughtcr of the deceased ThirujTmt. hereby declare that I have performed the last rites and funeral of the said ThirujTmt. wh<) expired on I have not obtained I applied for any financial assistance from any other source for the ~ame. , I further declare that the particulars above are troe and correct to the best of my knowledge and that I will repay tbe entire amount if tho particulars furnished by me found to be false on a later date. . SignatureTbumb-impression of the applicant. PART-m DF£LARATiON BY OrnER LEGAL HEIRS I/We. the undersigned to this declaration, hereby declare that I/We have no objection to make . payment for financial assistance towards funeral expenses of Thiru/Tmt. to the a~plicant. Thiru/Tmt. : -.. SI.No. Name and add~s Relationship with the deceased' Signature .;..."';;:. '2. 3. conFlCATE OF THE ANGANWADI WORKER I, Angallwadi worker of (Name of the centre) hel'eby declare that the deceased disabled persol1 Thiru{fmt. was receiving 6.llancial assistance through my centre and that he/she expired on.. The applicant ThirnjTmt. ~ performed the funeral of the deceased. Place 2 Date : Signature of the An~anwadi Workt'r
