FINANCIAL CONDITION REPORT Particulars of Ex-servicemen and his family for grant of Financial Assistance from Raksha Mantri's Discretionary Fund) 1. Name of the Applicant / Ex-servicemen_____________________________ 2. Service No. _____________________ Rank_________________________ 3. Address: ______________________________________________________ 4. Date of (a) Enrolment _________________ (b) Discharge_________________ 5. Reasons for discharge: _____________________________________________ (As given in Discharge Document) 6. Character at the time of Discharge ____________________________________ 7. In case of dependent, mention _______________________________________ Relation with the Ex-servicemen 8. Date of death of Ex-servicemen _______________________________________ (If applicable) 9. Particulars of family members:- (Details of all the children to be covered) Ser No Name Relationship with the Ex-servicemen Whether dependent / independent Age Occupation/ Monthly 10. Detailed report on the financial condition of the petitioner / petitioner's family:- (i) Was / is the Ex-servicemen in receipt of pension : Yes / No (ii) Is the applicant in receipt of pension : Yes / No (iii) Individual Pension / Service Pension / Family Pension / Invalidment Pension / Board Pension (iv) Total emoluments : Basic Rs _____________________ Insurance Relief Rs. ____________ Total Rs___________________ (v) Other terminal benefits at the time of requirement (such as Group Insurance Rs. __________________ Gratuity, Enhancement of leave) Rs. _________________ (vi) Land holding, if any______________________________________ Annual income from the land Rs. ____________________________ (vii) Income from any other source : Rs. __________________________ Such as rented houses, others) (viii) Present employment and income there from __________________ (ix) If reply to Para 10 (viii) is NIL, mention how he/ she is maintaining his / her family ______________________________ (x) Whether in receipt of second pension (From re-employment, if yes, state amount Rs_____________________ 11. Is / Was the Ex-servicemen re-employed ________________________ 12. If not, what was the source of income after retirement of the Armed force__ ____ 13. Financial Assistance received from various other sources Rs. ______________________ (Details of Financial Assistance (received from KSB, RSB, ZSB for any purpose in the post) 14. State whether financial assistance received from any source for self-employment (if any) was utilized for the purpose. ______________________ 15. Nature of Financial Assistance required _______________________________ (Applicant/ ZSB, is required to fill up the particulars given below in respect of the nature of financial assistance required only). 16. Assistance to old and infirm Ex-servicemen / Widow (Rs. 500/- per month for two years) (i) Whether the ESM / dependent is in receipt of old age / WW - II pension / financial assistance given by the state govt. under various state govt. schemes. (ii) If not eligible for old age / WW - II Pension / FA under any state Govt. scheme, the reasons thereof :______________________________ 17. Financial Assistance for Daughter's Marriage (Rs. 8000/-) (i) Actual date of solemnization _______________________ (ii) Whether confirmation certificate Marriage Invitation Card Attached: ____________________ (iii) How the marriage expenditure was met _________________ (iv) Details of loan taken for the purpose if any , and amount still outstanding Rs. ______________ 18. Medical Reimbursement (Up to a maximum of Rs. 15,000/-) (i) Whether the applicant approached MH / Govt. Hospital for treatment__________________________________________ (ii) If so, whether a copy of MH / Govt. Hospital reference enclosed ________ (iii) If not, the reasons for not approaching MH / Govt. Hospital ____________ (iv) If re-employed , details of medical benefit Schemes, if any , available with the re-employer ______________________________________________ (v) Whether the applicant is member of AGI / AFGI Medical benefit scheme? if so, the AGI / AGFI number ___________________________________ (vi) Whether summary of medical bills enclosed ________________________ (vii) Whether summary of medical bills enclosed________________________ (viii) Details of financial assistance provided from State Govt. funds in the instant case. if not reasons thereof _______________________________ 19. Grant for Children Education (Rs. 100/- per child for maximum of Children upto std) PER MONTH (i) Particulars of child / children from whom the education grant is applied for : Ser No. Name Name of School Class in which studying Year 2. Whether certificate obtained from the concerned school confirm date of birth and above details have been enclosed ___________________________________________ 3. Whether in receipt of scholarship / stipend for education from any other source____________ 20. Grant of House Repair (Upto a maximum of Rs. 10,000/-) (i) Cause of Damage___________________________ (ii) Estimate cost of repairs Rs. ________________________________ (iii) Whether certificate obtained from Gram Pradhan's enclosed ____________________________ (iv) Whether any relief given by the state / Govt. / Any other authority. if not reason thereof ____________________________________________ 21. Specific recommendation of secretary, Zila Sainik Board:- ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Date: Signature Office Seal Designation Note: The cases of Financial Assistance from RMDF are processed on the basis of information / particulars finished in the FCR form by the ZSB. The Zila Sainik Welfare Officers should ensure that the information / particulars given in the form are correct and an accordance with the discharge certificate and other documents.
