APPLICATION FORM FOR FINANCIAL ASSISTANCE FROM FLAG DAY FUND PART - I 1. Name:_______________________________________________________________ 2. Father's Name:________________________________________________________ 3. Age of the applicant: ___________________________________________________ 4. Regimental Number and Rank:____________________________________________ 5. Address - Village: __________________ Post Office ________________________ Tehsil ____________________ District: _________________________ 6. Unit in which last served: _______________________________________________ 7. Length of service: _________________Years,__________Months__________ Days. 8. Date and cause of discharge: _____________________________________________ 9. Cause of financial assistance: ____________________________________________ ____________________________________________________________________ 10. Amount applied for: Rs. _________________________________________________ 11. Amount of pension, if any: ______________________________________________ (State whether service, family or disability and in case of the last named, whether the disability was due to war or peace conditions).If not in receipt of pension, has one been applied for, and if so, when? 12. Amount of children's allowance, if any: ____________________________________ 13. Annual net income from other sources, if any:- i) Approximate area of any land: ______________________________________ ii) Irrigated: _______________________________________________________ iii) Un-irrigated: ___________________________________________________ iv) Estimated yearly net income from land: ______________________________ v) Estimated yearly net income from any other source: ____________________ 14. Amount of debts, if any: ________________________________________________ 15. Date, amount and source of any previous: __________________________relief grant also date of any previous application for a relief grant. 16. Whether the applicant is able bodied ____________________________and able to work for a living. If unable to work for a living, the reasons should be given. 17. Number of dependents giving relationship in all cases and, in that of Children, the sex and age of each (Dependents are Wife, Sons less than 18 years of age, unmarried daughters less than 18 years of age, Widowed Mother and Father if the latter is infirm and unable to support himself:- Name Age Relation Remarks Signature/Thump Impression of applicant PART II - Recommendation by the Welfare Worker:- 1. Summary of any reasons for ____________________ recommending financial assistance which are not already mentioned above. (if it is desired that the case should be treated as 'special' full reasons for such recommendations must be given). 2. Amount and nature of grant recommended: _________________________________ 3. Purpose for which, grant is to be devoted: __________________________________ Signature of Welfare Worker PART III - Amount Sanctioned/Not Sanctioned. Signature of DDSW/ADSW
