Annexure II FORM OF APPLICATION To The District Collector Kasargod. Through the Tahsildar of _______________________________. 1. Name in full (in CAPITAL LETTERS) 2. Full Address 3. Particulars regarding the Freedom Movement in which the Freedom Fighter participated together with dates during which and the Jail in which the imprisonment undergone. 4. Total income of the Freedom fighter claimant including help from near relatives. 5. Whether any other assistance has been received by the Freedom fighter claimant either from the Government of India or from the State Government. 6. Identification marks 1. 2. 7. I hereby declare that - (a) My income from all sources including help from near relatives is Rs,....... per month. (b) All the above particulars furnished by me are true and correct to the best of my knowledge. Place Date Signature of the applicant Copy to the District Collector, Kasargod (direct)
