APPLICATION FORM FOR specialized treatment UNDER PROSTHETIC AID SCHEME.
1 Name:-______
2 Parentage:-______
3 Residence:-______
4 Occupation:______
5 Would required ______Limb/ appliance. This is available at ______
6 Income of the family from all sources______
7 Type of Handicapped______
8 Kind of Orthopedic appliance required;______
9 Name of the institution and the place where such appliance / treatment is available ______
10 Approximately other charges :
Sig. of applicant
Medical Certificate:
I have examined Sh./Smt______S/o D/o W/o______R/o______and hereby certified that .
1. He/She is suffering from ______diseases and the applicant is a disabled /Crippled / Deaf & Dumb and is not in a position to move or Hear because of having ______deformity. Therefore he/ She shall be provided one number Hearing Aid/ Crutches/ Motorized Tricycle/ Wheel Chair/ Tricycle/ artificial limbs etc. So that he can be able to move or hear.
BMO/CMO______
Specialist
Income Certificate:
Certified that the income of the family of ______from all sources is Rs ______PM.
Seal & Sig of the Gazetted Officer.
Verification
I have personally verified the contents of the applicant and certify that the applicant is deserving one. The case may be covered under rules.
TSWO______
Govt of Jammu & Kashmir.
District Social Welfare officer, Kupwara.
Form No:- ______(Issued Free of cost.)
Application form for Grant of Assistance under Integrated Social Security Scheme (ISSS) /IGNOAPS. Indira Gandhi National Old Age Pension Scheme
(A) Block ______Constituency ______Tehsil ______
(Photograph)Name of the Applicant ______
D/o , W/o , S/o ______
R/O______
Identification Mark.______
Status of the Applicant.
(a) Old Age : Yes/No
(i) Single : Yes/ No with dependents Yes /No
(ii) If Yes then No of Dependents.______
(b) Physically Challenged : (State Category)
(i) Blind Yes /No (ii) Deaf & Dumb: Yes /No
(iii) Orthopedic Yes/ No (iv) Any other category: ______
( C) Women in Distress :
(i) Widow; Yes /No (ii) Destitute Yes/ No
(iii) Divorced Yes / No State No of Dependents:______
Signature/ Thumb Impression of the applicant.
Office of the Block Medical Officer______
(B)
Certified that I have examined Sh/ Smt ______S/o, W/o, D/o ______R/O ______and His / Her age is about ______Years Age in words ______
Block Medical Officer______
Seal & Signature of BMO
( C ) Verification of Tehsil Social Welfare officer ______
This is to certify that the contents of the application in respect of the applicant namely______S/o W/o D/o ______R/o ______Age ______Block ______are correct and the case is recommended to the district Level Committee for approval under ISSS/ IGNOAPS .
Sig. of dealing Assistant name & Sig of SW
TSWO______
Seal & Sig.
Date of Receipt :-______
(D)
Verification Report of Supervisor (ICDS) Zone ______of ICDS Project ______.
(Photograph)Name: ______
Parentage ______
Category:______
Widow/ Aged/ Divorced/ Destitute;
R/o ;______
Mohalla ______Village ______Block______Tehsil:______
Whether falling under BPL Category Yes/ No;
BPL R Card No :- ______
Name of BPL Ration Card Holder. ______
Details of the family
S. No / Name with Parentage / Relation with the applicant / Age / Occupation.Special recommendation if any ______
Name of Supervisor ______
With seal & Sig______
NO:- Sup/ICDS/______
Dated:- ______
Govt of Jammu & Kashmir.
District Social Welfare officer, Kupwara.
Form No:- ______
Application form for Grant of Assistance under National Family Benefit Scheme (NFBS ) (Issued Free of cost.)
(A) Block ______Constituency ______Tehsil ______
Name of the Applicant ______
D/o , W/o , S/o ______
R/O______
Name of deceased ______S/o ______R/O______Age ______
Occupation of the Deceased______
Annual Income of the family of the Deceased from all sources.______
Relation of the applicant with the deceased :- Wife / Son /Daughter /Father / Mother.
Date of Death :- / / Nature of Death:- ______
(Death Certificate from Municipal Committee/Police Station/ Health Deptt. Must be attached in Original)
Details of the family Members /Dependents of the deceased.
S.No / Name of the dependent. / Male /Female / Age / Relation with the deceased.1
2
3
4
Sig/Thumb impression of the Applicant
(B) Office of the Block Development Officer ______
BDO/ dated:-:-
It is to certify that the applicant namely ______S/o, D/o,W/o, ______R/o ______Block______
Is falling below poverty line and his /her annual income is Rs.______all suouces.
Seal & Sig. of BDO______
(C ) Verification of Tehsil Social Welfare Officer ______
It is certify that contents of the application in respect of the applicant namely ______age ______
S/o W/o D/o ______R/0______Block______
Are correct and the case is recommended to District Level Committee for approval under NFBS.
Sig of Dealing Asstt. Mane & Sig of S.Worker
Name & Sig. of TSWO.
(D)
Verification Report of Supervisor (ICDS) Zone ______of ICDS Project ______.
Name: ______
Parentage ______
Category:______
R/o ;______
Mohalla ______Village ______Block______Tehsil:______
Whether falling under BPL Category Yes/ No;
BPL R Card No :- ______
Name of BPL Ration Card Holder. ______
Details of the family
S. No / Name with Parentage / Relation with the applicant / Age / Occupation.1
2
3
4
5
6
Special recommendation if any ______
Name of Supervisor ______
With seal & Sig______
NO:- Sup/ICDS/______
Dated:- ______
ANNEXURE-I S. No:-___
APPLICATION FORM FOR ENGAGEMENT OF ANGANWADI WORKER.
1.Name of the District Kupwara. 2. Name of the ICDS Project:- Wavoora.
3. Name of the Anganwadi Centre for which engagement is sought ______
Panch Ward ______Panchayat______
4. Name of the Candidate (in Block letters)______
5. Fathers Name (in Block Letters)______
6. Martial States :- Married/ Un-Married.
7. Husband Name :-______
8. Place of permanent residence ______
Mohalla______Village ______
Punch ward constituency ______In Words______
Name of Panchayat ______House No:-______(as per electoral 2005)
Block :- Wavoora District :- Kupwara.
9. Address for correspondence______
10. Date of Birth ______
D / D / M / M / Y / Y / Y / Y11. Age as on 1-1-2009 ______
12. Academic Qualification
S.No. / Examination Passed / Board /School / Year of Passing / Marks obtained / Out of / %1
13. Experience if any :-______
14 Reserved category if any :- SC/ST/OBC/Social Cast/ ______
15. Physically Challenged if any :- Yes/ No . % of Disability ______
Nature of disability ______as per disability Certificate.
16. Documents attached .
A. Punch ward Certificate issued by BDO concerned .
B. Permanent residence certificate .
C. Academic qualification certificate with Marks Card Matric / Middle
D. Category Certificate issued by competent authority.
E. Disability Certificate In case of disability .
F. Self address envelope with postage stamp of Rs. 5/=
G. Experience Certificate If any.
Signature of Candidate.
Under taking.
I ______D/O ,W/o ______R/o ______
Do herby certify that the contents of the application given above are correct and true to the best of my knowledge. In case any of the above statement is found incorrect, the selection committee shall have the right to right my application and similarly revoke my engagement order issued on it.
Signature of Candidate.
APPLICATION FORM FOR SPECILIZED TREATMENT UNDER PROSTHETIC AID SCHEME.
11 Name:-______
12 Parentage:-______
13 Residence:-______
14 Occupation:______
15 Would required ______Limb/ appliance. This is available at ______
16 Income of the family from all sources______
17 Type of Handicapped______
18 Kind of Orthopedic appliance required;______
19 Name of the institution and the place where such appliance / treatment is available ______
20 Approximately other charges :
Sig. of applicant
Medical Certificate:
I have examined Sh./Smt______S/o D/o W/o______R/o______and hereby certified that .
1. He/She is suffering from ______diseases and the applicant is a disabled /Crippled / Deaf & Dumb and is not in a position to move or Hear because of having ______deformity. Therefore he/She shall be provided one number Hearing Aid/ Crutches/ Motorized Tricycle/ Wheel Chair/ Tricycle/ artificial limbs etc. So that he can be able to move or hear.
BMO/CMO______
Specialist
Income Certiificate:
Certified that the income of the family of ______from all sources is Rs ______PM.
Seal & Sig of the Gazetted Officer.
Verification
I have personally verified the contents of the applicant and certify that the applicant is deserving one. The case may be covered under rules.
TSWO______
APPLICATION FORM FOR ADMISSION IN SOCIAL WELFARE CENTRE :______
S.No______
Photograph1. Name :-______
2. Parentage :______
3. Residence:-______
4. Qualification:-______
5. Age of the applicant:-______
Undertaking:
I ______D/o, W/o ______R/o______do hereby agree to take admission in the social Welfare Centre______w.e.f.______
Signature of the candidate;
For office use only:
Submitted in original to Tehsil Social Welfare Officer ______for onward submission to District Social Welfare Officer, Kupwara;
I/C Social Welfare Centre
______
Duly endorsed, verified and forwarded with recommendation;
Tehsil Social Welfare Officer ,
______
APPLICATION FORM FOR MOTORIZED TRI CYCLE .
21 Name:-______
22 Parentage:-______
23 Residence:-______
24 Occupation:______
25 Would required ______Limb/ appliance. This is available at ______
26 Income of the family from all sources______
27 Type of Handicapped______
28 Kind of Orthopedic appliance required;______
29 Name of the institution and the place where such appliance / treatment is available ______
30 Approximately other charges :
Sig. of applicant
Medical Certificate:
I have examined Sh./Smt______S/o D/o W/o______R/o______and hereby certified that .
1. He/She is suffering from ______diseases and the applicant is a disabled /Crippled / Deaf & Dumb and is not in a position to move or Hear because of having ______deformity. Therefore he/ She shall be provided one number Hearing Aid/ Crutches/ Motorized Tricycle/ Wheel Chair/ Tricycle/ artificial limbs etc. So that he can be able to move or hear.
BMO/CMO______
Specialist
Income Certiificate:
Certified that the income of the family of ______from all sources is Rs ______PM.
Seal & Sig of the Gazetted Officer.
Verification
I have personally verified the contents of the applicant and certify that the applicant is deserving one. The case may be covered under rules.
TSWO______
r,
Proforma for pre-Matric Scholarship under District Plan
Name of the School______
S. No / Name with parentage / Class / Income(should not exceed 2100/-PM) / Whether RBA, OBC, Handicapped, Mochi Watls / % of Marks in previous Class (should not be less 55%) / %age of attendance
should not be less 80%) / Remarks
------
Seal & Sig of Head of the school C/sd by ZEO ______
GOVEREMNET OF JAMMU & KASHMIR.
SOCIAL WELFARE DEPARTMENT.
DISTRICT KUPWARA.
APLICATION FOR ISSUE OF MOTOTISED TRI-CYCLE.
TO PERSONS WITH DISABILITIES.
Photo Graph.FORM-1.
1. Name of the applicant…………………………………………
(And identification card Number)..
2. Name of the Father/Guardian………………………………………………
3. Address for communication ……………………………………………..
4. Date of Birth Day Month Year Age.
(Certificate to be enclosed)
5. Sex. Male/Female.
6. Nationality ……………………………….
7. Details of any other benefits availed
So for from this department.)…………………………………..
8. Nature of Disability. ……………………………………..
9. Contact Number……………………………………….
(Attached documents.)
10. Permanent Resident Certificate. (PCR) .
11. Ration card/ telephone bill.
12. Disability Certificate.
13. Annual Income Rs……………………………../=
14. Details of any other benefits availed
So for from this department.)…………………………………..
Whether he/she belongs to SC/ST
(Caste certificate to be enclosed).
15. Anganwadi Centre Name with code
Number near to your residence.
DECLARATION BY THE APLICANT/PARENT/GURADIAN.
I ……………………………………………………………………. Hereby declare that the particulars furnished above are correct and true to the best of my knowledge and the 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 Motorized Tri-Cycle. Further I declare on an oath that when Motorized Tri-Cycle is sanctioned in my favour I will never allow any body to use it and will not change colour deface of the Vehicle.
Signature of the applicant.
Signature of Parent/ Guardian.
FORM-II.
Department…………………………………..Office…………………………………………
ORDER.
Sanction is hereby accorded under Rule…………………of …………..to the grant of advance of Rs………………………..(Rupees …………………………………………………..) only to Shri………………………………………………………………………………..from his G.P fund account No;-……………………………………………………. to enable him to defray expenses on …………………………......
1. A sum of Rs………………………… (Rupees………………………………………………..) out of advance of Rs……………………………… sanctioned in ………………………….. and paid to him /her in…………………………………… will be outstanding till the commencement of the recovery of the consolidate amount as specified below:-
This amount together with the advance now sanctioned aggregating to Rs……………………………Rupees
……………………………………………………… only. recovered in………………………………….. monthly installment of Rs…………………………………………….each commencing from the salary for the month of …………………………………payable …………………………….
2. The balance at the credit of Shri…………………………………………….as on…………………..
Is detailed below :-
I. Balance as per account slip for the year ………………………. . Rs………………………………….
II. Subscription from……………………………… Rs…………………………………
Refunds from ……………………………….... Rs…………………………………
III. Total of Col I & II………………………………. Rs………………………………….
IV. Subsequently withdrawal, if any………………… Rs………………………………….
V. Balance as on date of sanction Col. (III) Minus (IV) Rs…………………………………
NO;-DSWO/Kup/Actt/2014/
DATED;- Sanctioning Authority.
APPLICATION FORM FOR RE-IMBURSEMENT OF EXMANINATION FEE / ITI STIPEND
1. Name of the student :-______
2. Parentage :______
3. Residence:-______
4. Class :-______10th,______12th ______( for re-imbursement of Examination fee ).
5. Course :- (for ITI) ______
6. Session :- ______
7. Date of Birth:-______
8. Name of the Institution:-______
9. Monthly income :- ______
(Income should not exceed 2100/=PM)
10. Bank Draft No;-______dated:- ______
Rs.______(only for re-imbursement of Examination fee).
Signature of the candidate;
For office use only:
1. Certified that the above contents of the student is correct.
2. Submitted in original to Tehsil Social Welfare Officer, Kupwara/ Handwara / Karnah.
Supdtt. ITI / Head of Instt.
______