Annexure -I ANDAMAN AND NICOBAR ADMINISTRATION DIRECTORATE OF SOCIAL WELFARE APPLICATION FOR THE GRANT OF FINANCIAL ALLOWANCES TO THE PERMANENT DISABLED HANDICAPPED PERSONS 1. Name of Applicant : (Block letters) One Passport Size Photo 2. Father's Name : 3. Married/Unmarried/Widow : 4. Sex : 5. Date of Birth : 6. Nature of permanent disability : (100%) Medical Certificates of disability to be enclosed. 7. Permanent Address : 8. Present Address : 9. Employment Registration No. : 10. Category : 11. Religion : 12. Occupation : 13. Details of the assistance received : from Govt./Local bodies/autonomous bodies. 14. Details of family members : 15. Period of assistance applied for : SINGNATURE OF THE APPLICANT CERTIFICATE TO BE FURNISHED FROM A REVENUE AUTHORITY NOT BELOW THE RANK OF TEHSILDAR Certified that Shri/Smti./Miss ...................... S/o, D/o/W/o ............... R/o............ is a permanent resident of this Union Territory of Andaman and Nicobar Islands for more than 10 years at the time of making this application. Signature Place : Name ............. Date : Designation ......... Office Seal .......... Contd.on..2.. : 2 : CERTIFICATE TO BE FURNISHED BY THE INVESTIGATOR Certified that the information furnished by Shri/Smt./Miss ....... .................S/o, W/o/D/o ............ R/o ............... has been verified and found correct. Place : Signature of the Investigator Date : with date and Seal. Countersigned Sanctioned Director(Social Welfare) Secretary(Social Welfare) A&N Admn., Port Blair. A&N Admn., Port Blair. (Verification on Non-judicial stamp paper not less than Rs. 2/-). AFFIDAVIT I.............. S/o, W/o,D/o.............. ..............R/o .................. aged .........years for hereby solemnly affirm and declare that :- 1. The particulars given by me in the application are true to the best of my knowledge and belief. 2. I am not in receipt of any other financial assistance or grant from any other sources. 3. I will refund the entire amount of assistance to the Govt. in case the information furnished by me proves wrong at any time. Place : Date : (Deponent)
