APPLICATION FORM FOR FINANCIAL ASSISTANCE FROM THE TAMIL NADU EXSERVICES PERSONNEL BENEVOLENT FUND Identity Card No. : NR No. : 1. Name of the applicant (Block letters) : 2. Full postal address : 3. If drawing pension, Pension Amount Whether Service pension OR Disability pension OR Family pension Treasury / Bank from which pension being drawn. : : : 4. Relationship between applicant and ex-Servicemen : 5. Applicant's Date of Birth and Age : 6. Is the applicant employed ? : Yes / No If employed, (i) Organisation in which employed : (ii) Post in which employed : (iii) Monthly salary : 6 (a) Employment of the ex-Servicemen after discharge from service : Salary : Civil Pension : 7. Is the applicant residing in own house OR rented house? : 8. Family Details : Sl. No. Name Age Relationship Details of what they do Monthly Income 9. Grant required and its purpose : (a) If required for conducting a daughter's marriage (i) Name of daughter : (ii) Her date of birth : (iii) Educational qualification of daughter : (iv) Proposed date of marriage : (b) If required for Artificial Limbs / Spectacles / Hearing Aid, etc (i) Purpose for which required : (c) If for Calamity Relief Grant details Damage due to fire, cyclone (i) Details of damages ( Total house damaged, roof damaged, one side wall damaged) : (ii) Amount required : (d) If required for Monthly Life Time Financial Assistance State whether suffering from (i) Leprosy : (ii) Cancer : (iii) Totally blind : (iv) Paraplegia : (v) Old Age : (vi) Tuberculosis : (f) If required for any other purpose, give full details : I certify that the above details are correct and true to the best of my knowledge. I enclose the relevant documents connected with my application. Signature of the Applicant. OR Left Thumb Impression Place : Date : If Left Thumb Impression, details of witnesses. Sl. Name & Address Signature No. 1. 2. EXTRACT OF DISCHARGE CERTIFICATE / SERVICE PARTICULARS Regimental No. : Rank : Name : Unit : Date of Enrolment : Date of Discharge : Cause of Discharge : State from which enrolled : Character : Identification Marks : 1. 2. Verified by me Superintendent / Welfare Organiser //Attested// Deputy/Assistant Director of Ex-Servicemen's Welfare, ..... ... .. District.
