Application Form for the grant of Pension to Widows/ Handicapped Old Age Person Under ISSS Scheme 1994 1. Name of Applicant __________________________ 2. Address Village/ Town __________________________ P/o _________________________ Tehsil__________________ Block _______________________ Panchayat ______________ Constituency ________________ District _______________ Photograph 3. Sub Caste __________________________ 4. Whether Male/ Female __________________________ 5. Name of Father/Husband __________________ 6. Age on the Date of Application (Proof to be enclosed)__________ 7. Status of the Applicant (a) Single man/ woman ____________ (b) Widow/Divorse above 40 yrs with No. of dependents (c) Orthepadically handicapped (Medical certificate with %age of disability (Certificate to be attached) 8. Income from all sources _________ p.m. I ..................S/o W/o / Wd/o __________________ R/o _________________do hereby affirm that the above particulars are correct to the best of my knowledge. In any case wrong information is incorporated I shall be liable for punishment. Signature of the applicant Certified that the applicant belongs Certified that the monthly income to below poverty line under of the family of the BPL Survey Applicant is Rs__________ P.M. in words____________ Block Dev. Officer Tehsildar (Signature with seal) (Signature with Seal) VERIFICATION REPORT Specific enquiry has been conducted by me and theparticulars as furnished by the applicant have been foundcorrect/incor rect, The request of the applicant falls within/do not fall within the purview of J&K Integrated Social Security rules 1994 Accordingly the case is recommended to the Tehsil Level Committee TEHSIL SOCIAL WELFARE OFFICER Stamp RECOMMENDATION OF THE COMMITTEE The application has been scrutinised and the applicant has been found eligible to the grant of Monthly pension CHIEF MED.OFFICER ASSTT.COMM.(DEV)) DISTT.S.W.OFFICER, KATHUA(MEMBER) KATHUA KATHUA(MEMBER SECY) DISTT.DEV. COMMISSIONER, KATHUA(CHAIRMAN)
