State of Tamilnadu- Act
Tamil Nadu Goldsmiths Social Security And Welfare Scheme, 2006
TAMILNADU
India
India
Tamil Nadu Goldsmiths Social Security And Welfare Scheme, 2006
Rule TAMIL-NADU-GOLDSMITHS-SOCIAL-SECURITY-AND-WELFARE-SCHEME-2006 of 2006
- Published on 1 September 2006
- Commenced on 1 September 2006
- [This is the version of this document from 1 September 2006.]
- [Note: The original publication document is not available and this content could not be verified.]
1. Short title, extent, application and commencement.
2. Definitions.
- In this Scheme, unless the context otherwise requires,3. Powers, duties and functions of the Board.
4. Secretary of the Board.
5. Appointment of Chief Executive Officer and other officers and staff.
6. Chief Executive Officer of the Board, etc., to be public servants.
- The Chief Executive Officer and other officers and staff of the Board appointed under this scheme shall be deemed to be public servants within the meaning of section 21 of the Indian Penal Code, 1860 (Central Act XLV of 1860).7. Administrative and financial powers of the Chief Executive Officer.
8. Opening of district and local offices.
- The Board may, with the approval of the Government, open district and local offices as it may consider necessary for the purpose of implementing the Scheme. It may also define the functions of such offices.9. Registration of manual workers.
10. Suspension and cancellation of membership.
11. Maintenance of registers.
12. The Tamil Nadu Goldsmiths Social Security and Welfare Fund.
13. Contributions.
14. Renewal of registration.
15. Intimation about change of employer, employment, place, etc..
- Every registered manual worker who leaves or changes his service under an employer, or changes his scheduled employment to another, or migrates from one place to another place shall, within thirty days of such change intimate the [Labour Officer (Social Security Scheme) of the respective district] [Substituted for 'Chief Executive Officer or any other officer authorized by the Chief Executive Officer in this behalf' by G.O. Ms. No. 122, dated 24.10.2008, published dated 31.10.2008.] by a letter sent by registered post or delivered in person.16. Utilisation of Fund.
17. Personal Accident Relief.
| (a) Death | Rs. 1,00,000 | |
| (b) Loss of actual physical separation of ortotal and irrecoverable loss of use of- | ||
| (i) both hands; or | Rs. 1,00,000 | |
| (ii) both feet; or | ||
| (iii) one hand and one foot; or | ||
| (iv) total and irrecoverable loss of sight in both eyes, | ||
| (c) Loss of actual physical separation of or total andirrecoverable loss of use of -(i) one hand; or | Rs. 50,000 | |
| (ii) one foot; or | ||
| (iii) total and irrecoverable loss of sight in one eye. | ||
| (d) Permanent total disablement from injuriesother than those specified in items (b) and (c) above. | Rs. 25,000 | |
| (e) Permanent partial disablement as specifiedin column (1) of the Table appended hereunder. | At the rate specified in the corresponding entryin column (2) of the Table below: |
| Nature of disablement | Compensation in percentage (to be applied onRs. 1,00,000) | ||
| 1 | 2 | ||
| Percent | |||
| 1 | Loss of toes | All | 20 |
| Great both phalanges | 5 | ||
| Great One phalanx | 2 | ||
| Other than great | 1 | ||
| if more than one toe lost each | 1 | ||
| 2 | Loss of hearing | Both ears | 50 |
| 3 | Loss of hearing | one ear | 15 |
| 4 | Loss of four fingers and thumb of one hand | 40 | |
| 5 | Loss of four fingers | 35 | |
| 6 | Loss of thumb | Both Phalanges | 25 |
| 7 | Loss of index finger | Three Phalanges | 10 |
| Two Phalanges | 8 | ||
| One Phalanx | 4 | ||
| 8 | Loss of middle linger | Three Phalanges | 6 |
| Two Phalanges | 4 | ||
| One Phalanx | 2 | ||
| 9 | Loss of ring finger | Three Phalanges | 5 |
| Two Phalanges | 4 | ||
| One Phalanx | 2 | ||
| 10 | Loss of little finger | Three Phalanges | 4 |
| Two Phalanges | 3 | ||
| One Phalanx | 2 | ||
| 11 | Loss of Metacarpal 1st or 2nd 3rd, 4th or 5th | (Additional) | 3 |
| (Additional) | 2 | ||
| 12 | Any other permanent partial disablement | Percentage as assessed by the Doctor. |
18. Pension Scheme.
- [(1) Eligibility. - Every registered manual worker who has complete 60 years of age is eligible for pension:Provided that a manual worker who has not completed 60 years of age, but registered with the Board is also eligible for pension, if he has become disabled due to sickness and incapacitated from normal work.] [Substituted by Notification No. II(2)/LE/90(m-14)/2011 vide G.O. Ms. No. 36, dated 28.02.2011,published dated 01.03.2011.]19. Assistance to meet the funeral expenses of a registered manual worker.
20. Assistance on the natural death of a registered manual worker.
21. Assistance for education of the son or daughter of a registered manual worker.
- [(1) The assistance for the education of the children of a registered manual worker shall be sanctioned by the Labour Officer (Social Security Scheme) of the respective district, after due verification, as specified in the Table below : -] [Substituted by G.O. Ms. No. 122, dated 24.10.2008, published dated 31.10.2008.][The Table] [Substituted vide G.O. Ms. No. 64, dated 1.3.2016, published dated 1.3.2016.]| Sl. No. | Form | Course of study | Day scholar | Hosteller | ||
| Boys | Girls | Boys | Girls | |||
| Rs. | Rs. | Rs. | Rs. | |||
| 1 | XI | 10th Std. studying - Girl children only | - | 1000 | - | - |
| 2 | X | 10th Std. passed | 1000 | 1000 | - | - |
| 3 | XI | 11th Std. studying - Girl children only | - | 1000 | - | - |
| 4 | XI | 12th Std. studying - Girl children only | - | 1500 | - | - |
| 5 | X | 12th Std. passed | 1500 | 1500 | - | - |
| 6 | XII | Studying regular Bachelor Degree course (Everyacademic year) | 1500 | 1500 | 1750 | 1750 |
| 7 | XII | Studying regular Post Graduate course (Everyacademic year) | 4000 | 4000 | 5000 | 5000 |
| 8 | XII | Studying regular Professional Course in Law,Engineering, Medicine, Veterinary Science and allied courses(Every academic year) | 4000 | 4000 | 6000 | 6000 |
| 9 | XII | Studying regular Post Graduate ProfessionalCourse in Law, Engineering, Medicine, Veterinary Science andallied courses (Every academic year) | 6000 | 6000 | 8000 | 8000 |
| 10 | XII | Studying ITI or Polytechnic course (Everyacademic year) | 1000 | 1000 | 1200 | 1200 |
22. Assistance for marriage.
23. Assistance for delivery or the miscarriage of pregnancy or the termination of pregnancy by registered female manual worker.
- [(1) The Labour Officer (Social Security Scheme) of the respective district shall, on an application from a registered female manual worker, sanction the assistance as indicated below, after due verification of the proof produced by her of her pregnancy or delivery of child by her or the miscarriage of her pregnancy or the termination of pregnancy:-| (i) Pregnancy | - Rs.6,000/- | |
| (Rs.3,000/- shall be paid on the seventh monthof pregnancy and remaining Rs.3,000/- shall be paid on deliveryof the child) | ||
| (ii) Miscarriage of pregnancy | -Rs.3,000/- | |
| (iii) Termination of pregnancy | -Rs.3,000/-.] |
24. Assistance for purchase of spectacles by a registered manual worker.
25. Eligibility to avail the benefits.
- A registered manual worker will be eligible to avail the benefits under this Scheme only if he has not availed similar benefits of any other Schemes of the Government.26. Penalty.
27. Mode of recovery of amount from employers.
- Any amount due from the employer in pursuance of the scheme shall, without prejudice to any other mode of recovery, be recoverable on behalf of the Board as an arrear of land revenue together with interest at such rate as may be notified by the Government.28. Power to remove difficulties.
- If, in the opinion of the Board, any difficulty or doubt arises as to the interpretation of any of the provisions of the Scheme or in the implementation of the Scheme, the Board shall refer the question to the Government and the decision of the Government shall be final and binding.29. Construction of reference to the registration, contribution, etc., under the Tamil Nadu Manual Workers Social Security and Welfare Scheme, 2001.
- The contribution made by any manual worker and the contribution made by an employer after registration and the consequential benefits accrued to any manual worker under the Tamil Nadu Manual Workers Social Security and Welfare Scheme, 2001, shall be construed as contribution made and the benefits accrued under this Scheme.[Form I [Substituted by G.O. Ms. No. 122, dated 24.10.2008, published dated 31.10.2008.]][See clause 9(2)]Application For Registration| AffixPassportsizephotograph |
| 1 | Name of the worker | : | |
| 2 | Name of the Father/Husband | : | |
| 3 | Date of Birth | : | |
| (enclose Xerox Copy of evidence in proof dulyattested by a Group A or Group B officer)* | Day Month Year | ||
| 4 | Marital Status | : | |
| (Whether married, unmarried, widow/widower) | |||
| 5 | Permanent address | : | |
| 6 | Present address | : | |
| 7 | State whether self-employed or employed | : | |
| 8 | If employed, furnish the name and address of theestablished and also the Name and address of the employercontractor | : | |
| 9 | Nature of work | : | |
| 10 | Number of years engaged in the employment as onthe date of application | : | |
| 11 | Particulars of the member of the family | : |
| Sl. No. | Name | Age | Relationship | Marital Status |
| 1 | 2 | 3 | 4 | 5 |
| 12 | (a) Whether the wife/husband is employed?(b) If so furnish details | : | |
| 13 | Nomination for receipts of Natural Death/ Accidental Death Assistance | : |
| Name and address **of be the nominee/nominees | Nominee’s Relationship with the worker | Age of the nominee | Percentage of amount to be paid to eachnominee |
| 1 | 2 | 3 | 4 |
| Place:Date: | Signature and name of the person/Officerissuing the certificate |
| Place:Date: | Village Administrative Officer/RevenueInspector(for Chennai district) |
| Official Seal: | Labour Officer (Social Security Scheme)District with date:Name:Designation:] |
| Identity Card | LabourStatue |
| 1. Accident Insurance Scheme | Rs. | |
| (a) Accidental Death | 1,00,000 | |
| (b) Accidental Disability | Based on Extent of Disability | |
| 2. Natural death assistance | 15000 | |
| 3. Funeral expenses assistance | 2000 | |
| 4. Educational assistance: - | ||
| (a) Girl children studying 10th | 1000 | |
| (b) 10th Passed | 1000 | |
| (c) Girl children studying 10th | 1000 | |
| (d) Girl children studying 12th | 1500 | |
| (e) 12th Passed | 1500 | |
| (f) Regular Degree Course | 1500 | |
| With Hostel Facility | 1750 | |
| (g) Regular Post Graduate Course | 4000 | |
| With Hostel Facility | 5000 | |
| (h) Professional Degree Course | 4000 | |
| With Hostel Facility | 6000 | |
| (i) Professional PG Course | 6000 | |
| With Hostel Facility | 8000 | |
| (j) I.T.I. or Polytechnic course | 1000 | |
| With Hostel Facility | 1200 | |
| 5. Marriage Assistance | 2000 | |
| 6. Maternity Assistance | 6000 | |
| 7. Reimbursement of cost of spectacles | up to 500 | |
| 8. Pension | 1000 |
| AffixPassport SizePhotograph |
| Registration No. | |||
| Date | |||
| 1. Name | : | ||
| 2. Father/Husband | : | ||
| 3. Date of Birth/ Age | : | ||
| 4. Employment | : | ||
| Registration should be renewed before.......... | |||
| 5. Permanent Address | : | ||
| 6. Present Address | : | ||
| 7. Marital Status | : | ||
| 8. Details of Nominees | : | ||
| 9. Registration Number if member of Trade Union | : | ||
| Signature of the Worker | Signature of the Officer |
| Details of Scheme assistance provided to theworker | |||||
| Sl. No. | Name of the assistance provided | Name of the beneficiary | File No and Date | Amount distributed | Signature of the officer |
8.
, Valluvar Kottam High Road, Nungambakkam Chennai - 600034 Phone: 2823 2129Form - III[See clause 11(1)]1. Name and address of the Employer
2. Name of the Establishment
| Register of contribution | ||||||
| Name of the worker | Registration No. | Nature of employment | Wages earned during the month | Total wages | Employers Contribution made to the Board | Particulars of D.D. (No., date and name of theBank) |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |
| Serial Number | Name of the Manual Worker | Name and address of the establishment (in caseof self employed worker, indicate the same) | Date of Registration | Registration Number |
| 1 | 2 | 3 | 4 | 5 |
1. Name and address
2. Name of the Establishment
Statement of Contribution| Sl. No. | Name of the worker | Registration No. | Nature of employment | Wages earned during the month | Total Wages | Employers Contribution made to the Board | Particulars of D.D. (No., Date and Name of theBank) |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
| Address:................................................................Date: | Signature of the worker/Nominee/Representative ofa Trade Union. |
| 1 | (a) Name of the registered manual worker | : | |
| (b) Address(in full) | : | ||
| (on the date of death/disability) | : | ||
| (c) Age | : | ||
| (d) Registration number and date of initialregistration | : | ||
| (e) Renewal date | : | ||
| (f) Occupation | : | ||
| 2 | (a) Area | : | |
| (b) Place | : | ||
| (c) District | : | ||
| 3 | (a) Name of the nominee | : | |
| (b) Relationship with the deceased registeredmanual worker(in the case of accidental death only) | : | ||
| (c) Age of the nominee | : | ||
| 4 | Whether the claimant is the registered worker?himself (in the case of accidental disability) or the nominee ofthe registered manual worker | : | |
| 5 | Date and time of accident | : | |
| 6 | Place of accident | : | |
| (a) at the work place | : | ||
| (b) outside the work place | : | ||
| 7 | Whether intimation regarding accident has beengiven in Form VI as per clause 17(3)(a)? | : | |
| 8 | Whether the accident resulted in death/ loss oflimb/loss of eye sight/partial injury? | : | |
| 9 | In the case of accidental disability, acertificate from a Civil Surgeon of the Government Hospitalindicating tire percentage of disability due to accident withdetails should be obtained and enclosed in original. | : | |
| [9-A [Inserted vide G.O. Ms. No. 64, dated 1.3.2016, published dated 1.3.2016.] | In case of accidental disability, whether theapplicant requires wheel chair/artificial limbs (strike outwhichever is not applicable)] | ||
| 10 | (i) Date and time of death(in case of accidentaldeath) | : | |
| (ii) Attested copy of First Information Reportfrom the Police Station nearer to the place of accident to beclosed | : | ||
| (iii) Post-Mortem Certificate and finalInvestigation Report should be sent in original | : | ||
| (iv) Death Certificate (attested copy) should beenclosed | : |
| Place:Date: | Signature/Thumb impression of theRegisteredManual Worker/Nominee in case of death. |
| Office Seal: | Labour Officer (Social Security Scheme)..............district. |
| Place : | (Affix Rubber Stamp) |
| Date: |
| Labour Officer (Social Security Scheme).......... district with date | |
| Name: | |
| Office Seal: | Designation: |
| AffixPassportsizephotograph |
1. Name of the Applicant
2. Address in full (to which pension is to be sent) (with PIN code)
3. Registration number and date (original Identity Card should be enclosed)
4. Age and date of completion of 60 years of age
Omitted vide G.O. Ms. No. 36, dated 28.02.2011, published dated 01.03.20116. Whether the registration has been renewed regularly without any default?
If so, details may be furnished| Sl.No. | Date of initial registration/Subsequentrenewal | Period of validity of registration/renewal | |
| From | To | ||
| 1 | 2 | 3 | 4 |
7. Whether in receipt of any other pension? If so, furnish complete details
Signature /Thumb impression of the registered Manual worker.Declaration*I hereby certify that the facts mentioned above are true to the best of my knowledge and information. I am not a registered manual worker of any other Board. If ultimately it is found that any of the information given by me is false, I agree to refund the entire amount received by me as pension besides any other action that may be deemed fit by the appropriate authorities.I also hereby declare that I have not received similar benefits by claim in any other Welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.| Place:Date: | Signature/Thumb impression of theRegistered Manual Worker.Name |
2. Incomplete application will not be considered.
SanctionI hereby sanction, after due verification, a monthly pension of Rs. ......../- (Rupees.............only) with effect from................ The amount shall be sent by money order.| Place:Date: | Labour Officer(Social Security Scheme)...........district |
| Passportsizephotographdulysigned |
1. Name of the Applicant
2. Address in full(to which pension is to be sent)(with PIN code)
3. Registration number and date (Original Identity Card should be enclosed)
4. Age and date of completion of 60 years of age
Omitted vide G.O. Ms. No. 36, dated28.02.2011, published dated 01.03.20116. Whether the registration manual worker of the Board regularly without any default?
If so, details may be furnished| Sl.No. | Date of initial registration/Subsequentrenewal | Period of validity of registration/renewal | |
| From | To | ||
| 1 | 2 | 3 | 4 |
7. Whether the applicant has become disabled due to sickness and incapacitated from normal work? (If so, a certificate by a Medical Officer not below the rank of Civil Surgeon of the Government Hospital under his name and seal should be enclosed in Original)
8. Whether in receipt of any other pension? If so, furnish complete details
Signature/Thumb impression of theRegistered Manual worker.Declaration**I hereby declare that the facts mentioned above are true to the best of my knowledge and information. I am not a registered worker of any other Board. If ultimately it is found that any of the information given by me is false, I agree to refund the entire amount received by me as disability pension besides any other action that may be deemed fit by the appropriate authorities.I also hereby declare that I have not received similar benefits by claim in any other Welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government Schemes.| Place:Date: | Signature/Thumb impression of the Registered Manual WorkerName: |
2. Incomplete applications will not be considered.
SanctionI hereby sanction after due verification a monthly pension of Rs......../-(Rupees ............only) with effect from.......... The amount shall be sent by money order.| Office Seal: | |
| Place :Date: | Labour Officer (Social Security Scheme)..............district. |
| Labour Officer (Social Security Scheme)............district with date | |
| Office Seal: | Name:Designation: |
| 1 | Name of the deceased registered manual worker | |
| 2 | Address in full(at the time of death) | |
| 3 | Age(on the date of death) | |
| 4 | Nature of work | |
| 5 | (a) Registration Number and date of initialregistration (original Identity card should be enclosed). | |
| (b) Date of last renewal, indicating the periodup to which renewed | ||
| 6 | (a) Place of death | |
| (b) Date of death | ||
| (c) Cause of death(to be indicated clearly)(Avoid indicating as "Natural Death") (DeathCertificate in original shall be enclosed) | ||
| 7 | (a) Name of the nominee | |
| (b) Age on the nominee(in completed years) | ||
| (c) Address of the nominee in full indicatingPIN Code | ||
| (d) Relationship of the nominee with thedeceased registered manual worker |
| Place:Date: | Signature /Thumb impression of the nominee of theRegistered Manual Worker. |
| Place:Date: | Members,...........Tamil Nadu..........Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
1. I hereby sanction, after due verification, a sum of Rs.............................../ (Rupees........................... only) as assistance to Thiru / tmt. / Selvi............., nominee/ nominees, for the funeral of Thiru/Thirumathi/Selvi ......................................a registered manual worker.
2. I hereby sanction, after due verification, a sum of Rs.............../- (Rupees.............. only) as assistance to Thiru/Tmt/Selvi............. nominee/ nominees, on the natural death of Thiru/Thirumathi/Selvi ............a registered manual worker.
| Office Seal: | Labour Officer (Social Security Scheme)............district |
| Date: |
| Labour Officer (Social Security Scheme)...............district with date | |
| Office Seal: | Name:Designation:] |
1. Name of the registered manual worker
2. (a) Registration Number and date of initial registration (original Identity card should be enclosed)
3. Address(in full) with PIN Code
4. Details of family members of the registered manual worker:-
| Sl.No. | Name | Relationship with the registered manual worker | Age |
| 1 | 2 | 3 | 4 |
5. Details of the son or daughter for whom educational assistance is sought for:-
| Sl.No. | Name (Son/ Daughter) | Date of Birth | Examination passed | Month and year of pass | Name of the School studied |
| 1 | 2 | 3 | 4 | 5 | 6 |
6. Number of children for whom the educational assistance has already been availed from the Board:-
| Sl.No. | Name | Son/ Daughter | Course for which assistance availed | Year of availing Assistance | Amount of assistance |
| 1 | 2 | 3 | 4 | 5 | 6 |
| Place:Date: | Signature/Thumb impression of theRegistered Manual Worker |
| Place:Date: | Members,...........Tamil Nadu..........Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
| Place:Date: | Labour Officer (Social Security Scheme)..........................district. |
| Labour Officer (Social Security Scheme)..........................district with date | |
| Office Seal: | Name:Designation:] |
1. Name of the registered manual worker
2. (a) Registration Number and date of initial registration (original Identity card should be enclosed)
3. Address (in full) with PIN Code
4. Details of family members of the registered manual worker:-
| Sl.No. | Name. | Relationship with the registered manualworker. | Age |
| 1 | 2 | 3 | 4 |
5. Details of the son or daughter for whom educational assistance is sought for: -
| Sl.No. | Name | Date of Birth | Standard in which studying(Std.10th/11th/12th). | Year of study (Indicate the academic year). | Name of the School with full address |
| 1 | 2 | 3 | 4 | 5 | 6 |
6. Number of children for whom the educational assistance has already been availed from the Board:-
| Sl.No. | Name | Son/ Daughter | Course for which assistance availed | Year of availing Assistance | Amount of assistance availed |
| 1 | 2 | 3 | 4 | 5 | 6 |
| Place:Date: | Signature/Thumb impression of theRegisteredManual Worker. |
| Place:Date: | Members,........................Tamil Nadu............................Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
| Office Seal | |
| Place:Date: | Labour Officer (Social Security Scheme)................district. |
| Labour Officer (Social Security Scheme)...........district with date | |
| Office Seal: | Name:Designation:] |
1. Name of the registered manual worker
2. (a) Registration Number and date of initial registration (original Identity card should be enclosed)
3. Address (in full) with PIN Code
4. Details of family members of the registered manual worker:-
| Sl.No | Name | Relationship with the registered manual worker | Age |
| 1 | 2 | 3 | 4 |
5. Details of the son or daughter for whom educational assistance is sought for:-
| Sl.No | Name | Son/ DaughterDate of birth | Name of the course studying | Duration of the course | Name of the College/ Institution with addressin full |
| 1 | 2 | 3 | 4 | 5 | 6 |
6. Number of children for whom the educational assistance has already been availed from the Board:-
| Sl.No | Name | Son/ Daughter | Course for which assistance availed | Year of availing Assistance | Amount of assistance |
| 1 | 2 | 3 | 4 | 5 | 6 |
| Place:Date: | Signature/Thumb impression of theRegistered Manual Worker. |
| Place:Date: | Members,..........................Tamil Nadu........................Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
| Place:Date: | Labour Officer (Social Security Scheme)..................district. |
| Labour Officer (Social Security Scheme)..................district with date. | |
| Official Seal: | NameDesignation |
1. Name of the registered manual worker
2. Registration Number and Date of initial registration (Original Identity Card should be enclosed)
3. Address in full with Pin Code
4. (a) Particulars of the members of the family of the registered manual worker:
| Sl. No. | Name | Relationship | Age | Marital Status |
| 1 | 2 | 3 | 4 | 5 |
| Place:Date: | Members,......................Tamil Nadu......................Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
| Place:Date: | Labour Officer (Social Security Scheme)..................district. |
| Labour Officer (Social Security Scheme)..................district with date. | |
| Official Seal: | NameDesignation |
1. Name of the registered female manual worker
2. (a) Registration Number and date of initial registration (Original Identity Card should be enclosed)
3. Address (in full) with PIN Code
4. Particulars of surviving son/daughter of the registered female manual worker
| Sl. No. | Name | Sex | Date of Birth | Age |
| 1 | 2 | 3 | 4 | 5 |
5. Month of Pregnancy* on the date of claim application
*(Certificate from the civil assistant Surgeon of the Government Hospital in support of this should be enclosed in original)6. Whether the claim is for pregnancy or miscarriage of pregnancy or termination of pregnancy? If so, details may be furnished. (Certificate from the Civil Assistant surgeon of the Government Hospital to this effect should be obtained and sent in original)
7. Whether the assistance has already been availed by the registered female manual worker? If so, details may be furnished
Signature/Thumb impression of the registered manual worker.Declaration by the Applicant*I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount received as assistance.I also hereby declare that I have not received similar benefits by claim in any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.| Place:Date: | Signature/thumb impression of theregisteredfemale manual worker. |
| Place:Date: | Members,........................Tamil Nadu.........................Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
| Office Seal: | Labour officer (Social Security Scheme)..............district. |
| Labour Officer (Social Security Scheme)..........................district | |
| Office Seal: | Name:Designation: |
1. Name of the registered manual worker
2. (a) Registration Number and date of initial registration (Original Identity Card should be enclosed)
3. Address (in full) with Pin Code
4. Date of purchase of spectacles and its actual cost
5. Whether certificate issued by a registered Opthalmist is enclosed in original?
6. Whether cash bill is enclosed in original?
Signature/Thumb impression of the registered manual worker.Declaration by the Applicant*I hereby declare that the particulars furnished above are correct and true to the best of my knowledge. In the event of any of the information given above is ultimately found to be false, I hereby agree to refund in full, the amount reimbursement towards purchase of spectacles for myself.I also hereby declare that I have not received similar benefits by claim in any other welfare Board or Boards constituted by the Government of Tamil Nadu or under any other Government schemes.| Place:Date: | Signature/thumb impression of theregistered female manual worker. |
| Place:Date: | Members,...........Tamil Nadu..........Welfare Board/President/Secretary of the RegisteredTrade Union of the Employment concernedAssistant Inspector of Labourconcerned/Any other officer permitted to giveEmployment certificate. |
| Office Seal: | Labour officer (Social Security Scheme)............district. |
| Labour Officer (Social Security Scheme)..........................district. | |
| Office Seal: | Name:Designation: |