PROFORMA-cum-RE QUISITION FOR SEEKING FINANCIAL ASSISTANCE FOR MEDICAL TREATMENT/EXGRATIA UNDER "CHIEF MINISTER's RELIEF FUND" To The Hon'ble Chief Minister, Govt. of Andhra Pradesh, Hyderabad. 01. Name of the Patient/Beneficiary : __________________________ (with Surname) 02. Father's/Husband's Name : __________________________ 03. Age : __________________________ 04. Permanent Address: H.No. : __________________________ Street/Village : __________________________ Mandal : __________________________ District : __________________________ Pin Code : __________________________ Phone No. (if any) : __________________________ 05. Address for Correspondence: H.No. : __________________________ Street/Village : __________________________ Mandal : __________________________ District : __________________________ Pin Code : __________________________ Phone No. (if any) : __________________________ 06. Name of the Disease/Purpose for seeking : __________________________ exgratia/financial assistance 07. Name & Address of Hospital with Phone : __________________________ & Fax Number __________________________ 08. Date of Surgery/Operation : __________________________ 09. Estimated/Requested Amount (Hospital : __________________________ estimation in ORIGINAL to be enclosed) 10. Whether any amount was sanctioned under : Source __________Amount:Rs. CMRF or from any other source 11. Ration Card/Income Certificate : ________________________ The above information given by me is true and correct as per my knowledge and I request you to sanction financial assistance under CMRF. Yours faithfully Place: Date: SIGNATURE OF THE PATIENT Enclosures: 1. Hospital Estimate in original 2. Copy of White Ration Card/Income certificate issued by the MRO. Latest Photo
