Section 7 in The Rajasthan Rules for Regulating the Fund for Grant of Exgratia Financial Assistance (Family Planning Acceptors) 1976
7.
In special hard cases, not covered under these rules, the District Level Committee may sanction ex-gratia payment, as may be considered proper in the interest of the programme, but in no case exceeding Rs. 500/-. The State Government may sanction ex-gratia payment upto Rs. 5000/- in such special hard cases.Appendix IForm of Application for Claiming Financial Assistance Under Rules for Regulating the Fund for Grant of Ex-Gratia Assistance, 1976(1)Name of the acceptor...............(2)Name of father/husband of the acceptor............(3)Age............(4)Caste.............(5)Business/profession/vocation................(6)Full address.............(7)Operated for tubectomy/vasectomy on...............at.....................Hospital/Dispensary/PHC/RFPC/RFPTC/UFPC/Camp..............District..............by Dr.............(8)Details pertaining to the claim:-(a)Nature of Complications............(b)When noticed............(c)Details of treatment given.........(d)Total duration of the treatment.........(e)If hospitalised, date of admission and discharge......(f)Name of doctors who attended the case...........(g)Date when declared physically fit/died..........(h)Cause of death.............(9)Details of expenditure for which assistance is claimed-(a)Cost of essential Medicines purchased for the treatment of complications...................(b)Transportation charges................(c)Special diet..............(10)In case of death-(a)Number of dependent surviving members of the deceased acceptor..............(b)Financial condition of the family........(c)Earning members in the family............I have verified the above facts in respect of Shri/Smt........ and recommend financial assistance of Rs............. towards the expenditure incurred by him/her in connection with the treatment of complications caused on account of Sterilisation/IUD insertion. The medicines purchased were essential for the recovery of the acceptor. These Medicines were not available in the............... Hospital for supply to the patient and do not include tonics, toilets, disinfectants, food etc.It is certified that the applicant or her husband/wife is not a Government servant and he is not entitled to get the expenses claimed above reimbursed through any other sources.Signature of the Medical OfficerIncharge of the case with seal.Signature of the applicant withfather/husbands name and full address.Signature of the Medical Officer Inchargeof the Hospital or Superintendent of theHospital in case of death case.CountersignedD. Chief Medical and Health Officer,(FP)District.............Rajasthan.
