FORMS COMMISSIONERATE DEPARTMENT OF INFORMATION AND PUBLIC RELATIONS SCHEME FOR FINANCIAL ASSISTANCE FROM WELFARE FUND FOR WORKING JOURNALISTS IN ANDHRA PRADESH DEPENDANTS IN DISTRESS ANNEXURE-I (to the G.O.Ms.No.1, G.A. (I&PR) Dept., Dt. 1-1-1986) To The Director of Information & Public Relations, Government of Andhra Pradesh, HYDERABAD. 1. Name in full (in capital letters) 2. Age and date of birth : 3. Full address : 4. In the case of living journalists :- a) Details regarding the service of the applicant as a journalist : b) Whether un-employed due to ill health : c) Whether un-employed due to overage : 5. In the case of families dependant of the deceased journalist :- a) Contribution of the deceased journalist to journalism : b) The applicant's relationship with the deceased journalist (whether widow/widower/son/un-married/daughter/father/mother) : 6. I hereby certify that :- a) My income from all sources is Rs.___________ per annum. b) All the above particulars furnished by me are true and correct to the best of my knowledge. Place : Date : SIGNATURE OF THE APPLICANT ANNEXURE-II (to the G.O.Ms.No.1, G.A. (I&PR) Dept., Dt. 1-1-1986) REPORT OF THE MANDAL REVENUE OFFICER/PRESIDENT/ SECRETARY OF WORKING JOURNALISTS UNION/DISTRICT PUBLIC RELATIONS OFFICER I have made necessary enquires regarding the statements in the application form of Sri/Smt. ____________________ and submit the following report :- 1) The applicant comes under the Scheme for giving financial assistance to Working Journalists/ Dependants in distress. 2) The journalist is un-employed due to ill health/ overage. 3) The applicant is the widow/widower/ son/unmarried/daughter/father/mother of the late ___________________ 4) The age of the applicant as verified from the certificates of date of birth furnished by the applicant or other reliable records (to be specified) is __________ years. 5) The total income of the claimant is Rs. ___________ 6) The particulars furnished by the applicant is/are Not correct. 7) Other remarks if any :- Place : Date : SIGNATURE Name and address with office seal
