APPLICATION FOR GRANT FROM RAKSHA MANTRI DISCRETIONARY FUND ( Particulars of Ex-Servicemen and his family for grant of assistance form Raksha Mantri's Discretionary Fund ) 1. Name of the Applicant : 2. Service No. : Rank/ Name : 3. Address : 4. Date of Enrolment : Discharge : 5. Reasons for Discharge : 6. Character at the time of Discharge : 7. In case of dependants, mention relationship with the Ex-Servicemen : 8. Date of birth/Age of the applicant : 9. Particulars of family members :- 10. Detailed report on the financial condition petitioner family Sl. No. Name of the relationship Whether dependant /Independent Age Occupation Monthly Income 1) Was/is the ex-Servicemen in receipt of pension 2) Is the petitioner in receipt of pension 3) Nature of pension : Service / Family / Disability Pension 4) Total emoluments : Basic Rs. D.A. Rs. Total Rs. 5) Other terminal benefits at the time of retirement : 6) Land holding, if any : Annual income from land : 7) Income from any other sources : (like rented house, other properties) 8) Present employment : 9) whether in receipt of second pension ( i.e. from re-employment) 11. Is / Was the ex-Serviceman re-employed : 12. If not re-employed what was the source of income after retirement : 13. Financial Assistance received from various other sources : 14. State whether financial assistance received from any other sources for self employment (if any) was utilised for the purpose : 15. Nature of financial assistance required : ( Applicant /ZSB is required to fill up the particulars given below in respect of the nature of financial assistance required only) 16. Assistance to Old And Infirm ex-Serviceman/widow ( Rs.1000/- p.m. for two years i) Whether ESM / dependant is in receipt of old age/WW II pension / financial assistance given by the State Govt. under various State Govt. Schemes: ii) If not eligible for old age/WW II pension / FA under any State Govt. schemes the reasons thereof: 17. Financial Assistance for Daughter's Marriage ( Rs.8000/-) i) Actual date solemnisation: ii) Whether confirmation certificate/ Marriage Invitation Card attached : iii) How the marriage expenditure was met: iv) Details of loan taken for the purpose, if any, and amount still outstanding : Rs. 18. Medical Reimbursement ( Upto a maximum of Rs.15,000/i) Whether the applicant approached MH/Govt. Hospital for treatment : ii) If so, whether a copy of MH / Govt.Hospital reference enclosed : iii) If not, the reasons for not approaching MH/Govt. Hospital : iv) If re-employed , details of medical benefit schemes if any, available with the re-employer : v) Whether the applicant is member of AGI /AGFI Medical benefit scheme? if so, the AGI/AGFI number : vi) Whether original medical bills/receipts have been countersigned by competent medical authority? : vii) Whether summary of medical bills enclosed : viii) Details of financial assistance provided from State Govt. funds in the instant case, if not reasons thereof? : 19. Grant for children education (Rs.100/-p.m. per child for maximum of 3 children upto XII std. i) Particulars of child/children from whom the education grant is applied for:- ii) Whether certificate obtained from the concerned school confirming the date of birth and above details have been enclosed iii) Whether in receipt of scholarship/stipend for education purpose from any other sources: 20. Grant for house repair ( upto a maximum of Rs.10,000/-) 1. Cause of damage : 2. Estimated cost of repairs : Rs. 3. Whether certificate obtained from Gram Pradhanis enclosed : 4. Whether any relief given by the State Govt./ Other authority? if not the reasons thereof: 21. Specific recommendations of Secretary, Zila Sainik board:- Date: Signature: Office Seal : Designation: Note: The cases of financial assistance from RMDF are processed in the basis of information / particulars furnished in the FCR form by the ZSB. The Zila Sainik Welfare Officers should ensure that information / particulars given in the form are correct and in accordance with discharge certificate and other documents. No column should be left blank
