APPLICATION FOR PAYMENT OF TRANSPORT ALLOWANCE TO DISABLED PERSONS 1. Name of the Applicant 2. Father's /Guardian's Name 3. Sex Male/Female 4. Whether the applicant belongs to SC/ST? If yes, attach a certificate obtained from the Revenue Department. 5. Date of Birth/Age (Attach an attested copy of the Birth Certificate/ Age Proof). 6. Whether a Resident I Native of Pondicherry Union territory? If yes, attach a certificate in the Prescribed form obtained from the Revenue Department, 7. Annual Income (Attach ~ certificate in the prescribed form obtained from the Revenue Department). 8. Nature and extent of disability (Attach an attested copy of the disability certificate issued by the Health Department) (i) Whether the applicant is a student? (ii) If yes, whether he/she is in receipt of any allowance from the Government towards his/her conveyance? (iii) If so, please furnish the details. 9. Whether the applicant has already obtained a free bus pass from the Department of social .Welfare? If yes, please enclose the same : 10. Address for communication Signature of the Applicant DECLARATION I hereby declare that the particulars furnished above are correct and true; to the best of my knowledge and that I have not received any financial assistance for conveyance purpose from the Department of Social Welfare or from any other source. I have not suppressed any material information that makes me ineligible to receive this allowance. I understand that the sanction to be issued on the strength of the above information is liable to be cancelled if it Is found that the information. I furnished by me is proved to be incorrect and false. Signature of the Applicant Signature of the Parent Guardian
