APPLICATION FOR GRANT TOWARDS MAJOR SURGERIES 1. (a) Regimental Number (b) Rank (c) Name ( IN BLOCK LETTERS) (d) Date of enrolment/Commission (e) Date of Discharge/Release/Retirement (f) Cause of Discharge (g) Character (h) Date of Birth / Present Age (i) Identification Marks (j) Pension, if any (i) Type of Pension (ii) Amount (iii) PPO No. (iv) Place of Drawing Pension (k) Place of Enrolment ( in case of Officers certificate of service from Service Headquarters is required) 2. Permanent Address 3. Present Address 4. Details of Dependants Name Relation- Age Occupation Monthly ship Date of income Birth if any (1) (2) (3) (4) (5) 5. Present Financial Status of the applicant (a) Pension (b) Salary, if re-employed (c) Income from self employment (d) Rentals from Building (e) Agricultural Income (f) Dividends from shares etc. (g) Interest on Fixed Deposits (h) Other Income (h) Total Monthly Income 6. Details of Immovable property Immovable Property : (a) Land : Urban/Rural Area TotalValue Income (i) Agricultural (ii) Non - Agricultural (b) House(s) : (i) (ii) (c) Commercial : (i) (ii) 7. Details of Applicant's Bankers (a) Name of Bank and Branch (b) Postal Address (c) Account Number ( Savings/ Current Account) 8. Details of Major Surgery required - (a) Type of Surgery (b) Where is it proposed to be conducted ( Name of the Hospital and Postal Address) (c) Name of Doctors who will be performing the surgery. (d) What is the total cost of surgery ( Attach certificate) 9. Details of Financial Assistance received/applied Sources Amount (a) (b) (c) (d) Total 10. How much of the cost of Surgery will be borne by you? 11. Have you attached relevant certificates? 12. Have you applied for assistance from AGIMBS/AFMBS/Naval BF/Kendriya Sainik Board. 13. If not the reasons for not applying Certified that all the above facts have been correctly revealed and no information has been concealed to the best of my knowledge and undertake to refund the amount if found fake. I undertake to refund the amount if it is found that any information furnished is to be incorrect. Date: Signature of the Applicant Caution: Any wrong declaration or concealing of facts may adversely affect consideration of the application and may debar you from any further assistance/ financial help. PART - II 1. CERTIFICATE FROM THE AUTHORISED MEDICAL OFFICER This is certify that Ex.No................... Rank........... . Name................. .. is suffering from ............. and requires ........... surgery in order to cure him. This surgery is certified to be absolutely essential. The surgery will be conducted by the following Surgeons (a) (b) (c) (d) The surgery will be performed at - (name and address of Hospital) .................... ... ..................... ..................... The total cost of Surgery is likely to be Rs... ....... .. (Rupees.... .............................. ... .only) Place: Signature Date: (Name in BLOCK LETTERS) Seal: Designation The certificate should be signed by any one of the following : 1. Surgical Specialists of the Military hospital 2. Civil Surgeons Specialists of the Tamil Nadu State Government 3. Doctors who are recognised to be specialists in the concerned field of surgery PART - III Certificate No. Date: INCOME CERTIFICATE ( Pension/ Pay/Business/ landed property ) This is to certify that the Total income of Ex.No............... Rank.............. Name............................... . from all sources is Rs........ ..(Rupees............. ........................ only) per annum. Office Seal Place : Certifying Officer Date : (NAME IN BLOCK LETTERS) Designation This certificate should be signed only by the Officer of the Revenue Department not below the rank of Tahsildar PART - IV DEPUTY DIRECTOR/ASSISTANT DIRECTOR OF EX-SERVICEMEN'S WELFARE CERTIFICATE This is to certify that Ex.No......... ..Rank..... . Name................ ..... . is eligible to obtain financial assistance under the Rules of the Tamil Nadu Ex-services Personnel Benevolent Fund. The Service particulars furnished by him, have been verified by me personally and found correct. This ex-servicemen is not black listed or debarred form obtaining financial assistance from Tamil Nadu Ex-services Personnel Benevolent Fund. This ex-servicemen is a loanee/ not a loanee from Amalgamated funds This ex-servicemen is not a defaulter in Bank Loan. The details of assistance rendered by this office is as under: 1. 2. 3. 4. 5. The details of family particulars have been verified by me and found correct. The ex-serviceman has registered in this office under Nominal Roll Number............ .. I recommend that he may be given financial assistance for major surgery Office Seal Deputy Director/ Date Assistant Director of Ex-Servicemen's Welfare
