SPORTS DEVELOPMENT AUTHORITY OF TAMIL NADU 116-A, Periyar EVR High Road, Nehru Park, Chennai-84 PENSION TO THE OUTSTANDING SPORTS MEN / WOMEN WHO ARE IN INDIGENT CIRCUMSTANCES Application Form for Sports (Men / Women) Pension PHOTO Eligibility 1. Should have secured any one of the first three places in individual events in the Inter-District (or) State Championship conducted by the recognized State Sports Association. 2. As on 1st April / The applicant should have completed 58 years of age. 3. Income ceiling is Rs.500/-per month 4. Those who are in receipt of Sports Pension for Govt. of India are not eligible for the Scheme. SDAT have the right to cancel or reject the application at any point of time. 1. a) Full name of the applicant : in Block Letter b) Father's name : c) Permanent Address : 2, Date of Birth and age completed : (Certificate to be enclosed) 3. How many years are you the : resident of Tamil Nadu 4. Details of last occupation a) Designation : b) Name and address of the office: 5. Are you getting any pension : YES / NO (or) if yes, the details 6. Performance and achievements in Sports Performance in the District / State Championships conducted by State Sports Associations. Sl. Discipline Name of the Venue and Date Position No. competition secured Attach the attested copies of Merit Certificates 7. Performance in the National Competition conducted by the National Federations and All India / South Zone Tournaments conducted between Universities. Discipline Name of the Venue and Date Position Sl. competition secured No. Attach the attested copies of Merit Certificates 8. Performance in sports activities at International level Discipline Name of the Venue and Date Position Sl. competition secured No. Attach the attested copies of Merit Certificates 9. Whether the applicant's wife : YES / NO employed or not a) If employed (Name of : office address) b) Monthly income : 10. Details of Family Members Sl. Name of the No. Member Age Occupation Relationship Monthly Income 11. Details of property : (Movable/Immovable) and income from the assets 12. Monthly income : (including pension) 13. Income certificate should be : obtained from the concerned Tahsildar NOTE: Application without income certificate will be rejected. I hereby affirm that the particulars given by me in the application are correct to the best of my knowledge and belief. Place: Date: Signature of the Applicant Report of the District Sports Officer 1. Applicant's Name : Age : Address : 2. Applicant monthly income : (Whether the income certificate issued by Tahsilder or not) 3. The copies of sports certificate are compared with originals and I certify that the these copies are correct. Place: Date: Signature of the District Sports Office Seal Officer. Recommendation of the District Collector Certified that the application in respect of Thiru / Tmt.__________________________________________ who is in indigent circumstances, is hereby recommended for the sports person pension scheme based on the income certificate issued by Tahsildar and on the certificate by the District Sports Officer after verification of sports certificates. Place: Date: Office Seal Signature of the District Collector Application forwarded
