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Union of India - Section
Section 45 in The Person With Disabilities (Equal Opportunities, Protection Of Rights And Full Participation) Rules, 1996
45. Submission of annual report
.-(1) The Chief Commissioner shall as soon as possible after the end of the financial year but not later than the 30th day of September in the next year ensuing, prepare and submit to the Central Government an annual report giving a complete account of his activities during the said financial year.| 1. | Name.................. | .......... | .......... |
| (Surname) | (First name) | (Middle name) | |
| 2. | Father's name.................... | Mother's name.................... | |
| 3. | Dateof Birth :________/ _______/ _______/(Date)(Month) (Year) | ||
| 4. | Age at the time ofapplication : ________ Years | ||
| 5. | Sex : | Male/Female | |
| 6. | Address : | ||
| (a) | Parmanentadress................................................................ | (b) CurrentAddress (i.e. forcommunication)................................................................ | |
| (c) Period sincewhen residing at current address------------------------------------- | |||
| 7. | Education Status(Pl. tick as applicable) | ||
| (I) Post Graducate | |||
| (II) Graduate | |||
| (III) Diploma | |||
| (IV) HigherSecondary | |||
| (V) High School | |||
| (VI) Middle | |||
| (VII) Primary | |||
| (VIII) Illterate | |||
| 8. | Occupation------------------------------------------------- | ||
| 9. | Identificationmarks (i) ........... | (ii)............. | |
| 10. | Nature ofdisability : locomotor/hearing/visua/mental/others | ||
| 11. | Period since whendisabled : From Birth/Since Year ---------- | ||
| 12. | (i) Did you everapply for issue of a disability certificate in the past ------YES/NO | ||
| (ii) If yes,detaisl : | |||
| (a) Authority towhom and district in which applied ------------------ | |||
| (b) Result ofapplication --------------------------- | |||
| 13 | Have you ever beenissued a disability certificate in the past? If yes, pleaseenclose a ture copy. | ||
| Declaration: I hereby declare that all particulars stated above are ture tothe best of my knowledge and belief, and no material informationhas been concealed or misstated. I further, state that if anyinaccuracy is detected in the application, I shall be liable toforfeiture of any benefits derived and other action as per law. | |||
| ---------------------------(Signatureor left thumb impression of person with disability, or of his/herlegal guardian in case of persons with mental retardation autism,cerebral palsy and multiple disabilities) | |||
| Date : | |||
| Palce : | |||
| Encl : | |||
| 1. | Proof of residence(Please tick as applicable) | ||
| (a) ration card. | |||
| (b) voter identitycard, | |||
| (c) drivinglicense, | |||
| (d) bank passbook | |||
| (e) PAN Card, | |||
| (f) Passpost, | |||
| (g)telephone, electricity, water and any other utility billindicating the address of the applicant, | |||
| (h)a certificate of residence issued by a Panchyat, municipality,cantonment board, any gazzetted officer, or the concerned Patwarior Head Master of a Govt. School, | |||
| (i)in case of an inmate of a residential institution for personswith disabilities, destitute, mentally ill, etc., a certificateof residence from the head of such institution. | |||
| 2.Two recent Passport size photographs----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | |||
| (Foroffice use) | |||
| Date : | |||
| Palce : | Signature ofissuing authority stamp |
| RecentPP size Attested Photograph (Showing face only of the person withdisability |
| Certificate No. | Date : | |
| This is to certifythat I have carefully examined | ||
| Shri/Smt/Kum.__________________________________ son/wife/daughter of shri_______________________________________ | ||
| Date of Birth ______ ___ Age ______ years, male, female ______________ | ||
| (D/MM/YYY) | ||
| RegistrationNo._______________ Parmanent resident of House No.________________ Ward/Village/ Steet____________PostOffice______________________District ______________ State_______________. | ||
| Whose photographis affixed above, and am satisfied that : | ||
| (A) he/she is caseof : | ||
| locomotor disability | ||
| Blindness(Pleasetick as applicable) | ||
| (B) | the diagnosis inhis/her case is ............ | |
| (A) | He/She/has...............%(in figure).....................Percent | |
| (in words)permanent physical impairment/blindness in relation to his/her-----------(Part of body) as per guidelines (to bespecified). | ||
| 2. The applicanthas submitted the following document as proof of residence :- |
| Nature of Document | Date of Issue | Details ofauthority issuing certificate |
| (Signatureand Seal of Authorised Signatory of notified medical Authority) |
| Signature/Thumbimpression of the person in whose favour disability certificateis issued |
| RecentPP size Attested Photograph (Showing face only of the person withdisability |
| Certificate No. | Date : | |
| This is to certifythat We have carefully examined | ||
| Shri/Smt/Kum.__________________________________ son/wife/daughter of shri_______________________________________ | ||
| Date of Birth ______ ___ Age ______ years, male, female ______________ | ||
| (D/MM/YYY) | ||
| RegistrationNo._______________ Parmanent resident of House No.________________ Ward/Village/ Steet____________PostOffice______________________District ______________ State_______________. | ||
| Whose photographis affixed above, and are satisfied that :(A) He/She is a Case ofMultiple Disability.His/her extent of permanent physical impairment/disability has been evaluated as per guidelines (to be specified) for the disabilities ticked belwo, ans shown aginst the relevant disability in the table below : |
| S.No. | Disability | Affected Partof BodyE | Diagnosis | PermanentPhysical impairment/mental disability (in %) |
| 1 | Locomotordisability | @ | ||
| 2. | Low vision | # | ||
| 3 | Blindness | Both Eyes | ||
| 4 | Hearing impairment | £ | ||
| 5 | Mental retardation | X | ||
| 6 | Metal-Illness | X |
| (B) In the lightof the above, his/her over all permanent physical impairment asper guidelines (to be specified), is as follows :- |
| In figures :-___________________________percent |
| In words :-__________________________________________________percet |
| 2.This conditionis progressive/non-progressive/likely to improve/not likely toimprove |
| 3. Reassessment ofdisability is : |
| (i) not necessary, |
| or |
| (ii)is recommended/after _________years_________months, and thereforethiscertificate shall be valid till _________ _________________(DD)(MM) (YYYY) |
| @ e.g.Left/Right/both arms/legs |
| # e.g. Singleeye/both eyes |
| £ e.g.Left/Right/both ears |
| 4. The applicanthas submitted the following document as proof of residence :- |
| Nature of Document | Date of Issue | Details ofauthority issuing certificate |
| 5. Signature andseal of the Medical Authority. |
| Name and seal ofMember | Name and Seal ofMember | Name and seal ofthe Chairperson |
| Signature/Thumbimpression of the person in whose favour disability certificateis issued |
| RecentPP size Attested Photograph (Showing face only of the person withdisability |
| Certificate No. | Date : | |
| This is to certifythat I have carefully examined | ||
| Shri/Smt/Kum.__________________________________ son/wife/daughter of shri_______________________________________ | ||
| Date of Birth ______ ___ Age ______ years, male, female ______________ | ||
| (D/MM/YYY) | ||
| RegistrationNo._______________ Parmanent resident of House No.________________ Ward/Village/ Steet____________PostOffice______________________District ______________ State_______________. | ||
| Whose photographis affixed above, and am satisfied that he/she is a case of ______________disability. His/her extent of percentage physical impriment/disability has been evaluated as per guidlines (to be specified) and is shown agaisnt the relevant disability in the table below :- |
| S.No. | Disability | Affected Partof Body | Diagnosis | PermanentPhysical impairment/mental disability (in %) |
| 1 | Locomotordisability | @ | ||
| 2. | Low vision | # | ||
| 3 | Blindness | Both Eyes | ||
| 4 | Hearing impairment | £ | ||
| 5 | Mental retardation | X | ||
| 6 | Metal-Illness | X |
| (Please strike out the disabilities which are not applicable.) |
| 2. The above condition is grogressive/non-progressive/likely to imporve/not likely to improve. |
| 3. Reassessment ofdisability is : |
| (i) not necessary, |
| or |
| (ii)is recommended/after _________years_________months, and thereforethiscertificate shall be valid till _________ _________________(DD)(MM) (YYYY) |
| @ e.g.Left/Right/both arms/legs |
| # e.g. Singleeye/both eyes |
| £ e.g.Left/Right/both ears |
| 4. The applicanthas submitted the following document as proof of residence :- |
| Nature of Document | Date of Issue | Details ofauthority issuing certificate |
| (AuthorisesSignatory of notified Medical Authority)(Name and Seal)Countersigned |
| {Countersignatureand seal of the Government Hospital, in case the certificate isissued by a medical authority who is not a government servant(with seal) |
| Signature/Thumbimpression of the person in whose favour disability certificateis issued |
| Note : In casethis certificate is issued by a medical authority who is not agovernment servant, it shall be valid only if countersigned bythe Chief Medical Officer of the District." |
| Note : Theprincipal rules were published in the Gazettee of India videnotification number S.O. 908(E), dated the 31st December, 1996. |
| No._____________________ | Date : |
| To, | |
| (Nameand address of applicant for Disability Certificate) | |
| Sub : Rejection ofApplication for Disability Certificate | |
| Sir/Madam, | |
| Pleaserefer to your application dated __________ for issue of aDisability Certificate for the following disability :_______________________________________ | |
| 2. Pursuant to theabove application, you have been examined by theundersigned/Medical Board on ___________, and I regret to informthat, for the reasons mentioned below, it is not possible toissue a disability certificate in your favour : | |
| (i) | |
| (ii) | |
| (iii) | |
| 3. In case you areaggrieved by the rejection of your application, you may representto _______________________________________________, requestingfor review of this decision. | |
| Yoursfaithfully,(AuthorisedSignatory of the notified Medical Authority(Name and Seal) |
| No._____________________ | Date : |
| To, | |
| (Nameand address of applicant for Disability Certificate) | |
| Sub : Rejection ofApplication for Disability Certificate | |
| Sir/Madam, | |
| Pleaserefer to your application dated __________ for issue of aDisability Certificate for the following disability :_______________________________________ | |
| 2. Pursuant to theabove application, you have been examined by theundersigned/Medical Board on ___________, and I regret to informthat, for the reasons mentioned below, it is not possible toissue a disability certificate in your favour : | |
| (i) | |
| (ii) | |
| (iii) | |
| 3. In case you areaggrieved by the rejection of your application, you may representto _______________________________________________, requestingfor review of this decision. | |
| Yoursfaithfully,(AuthorisedSignatory of the notified Medical Authority(Name and Seal) |
| Name and Address of the Employer | :________________________________________________________________ |
| Whether-Head Office | :________________________________________________________________ |
| Branch Office | :________________________________________________________________ |
| Nature of business/principal activity | :________________________________________________________________ |