Sonwifedaughter of shri date of birth ddmmyyyy age

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……………………………………………..…………….. son/wife/daughter of Shri……………………………… Date of Birth…………………… (DD/MM/YYYY) Age ………….years, Male/Female……………………Registration No. …………… ......... Permanent Resident of House No. ….….. Ward/Village/Street ……………….……………..whose photograph is affixed above and I am satisfied that He/She is a case of ____________________________________________________________________ Disability . His/Her extent of permanent physical impairment/disability has been evaluated as per guidelines (to be specified) for the disabilities ticked below and shown against the relevant disability in the table below: S. No. Disability Affected Part of Body Diagnosis Permanent Physical Impairment/ Mental Disability (in%) 1 Locomotor Disability @ 2 Muscular Dystrophy 3 Leprosy cured 4 Cerebral Palsy 5 Acid attack Victim 6 Low Vision # 7 Deaf £ 8 Hard of Hearing £ 9 Speech and Language disability 10 Intellectual Disability 11 Specific Learning Disability 12 Autism Spectrum Disorder 13 Mental-illness 14 Chronic Neurological Conditions 15 Multiple Sclerosis 16 Parkinson ’s Disease 17 Haemophilia 18 Thalassemia 19 Sickle Cell disease (B)In the light of the above, his/her over all permanent physical impairment as per guidelines (to be specified), is as follows: In figures: ………………………..percent In words: …………………………………………percent 2. Thisconditionisprogressive/non-progressive/likelytoimprove/notlikelytoimprove. 3. Reassessment of disability is: i) Not necessary, Or ii) is recommended/after ……………….Year ……………………months, and therefore this certificate shall be validtill …………………………………………… (DD/MM/YYYY) @ e.g. Left/Right/both arms/legs; # e.g. Single eye/both eyes; £e.g. Left/Right/both ears Recent PP Size Attested Photograph (Showing face only) of the Person with disability
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Page 24 of 35 4. T he applicant has submitted the following documents as proof of residence Nature of Document Date of issue Details of authority issuing signature Countersigned[(Countersignature and seal of the CMO/Medical Supdt.)Superintendent/Head of Government Hospital in case the certificate is issued by a medical authority who is not a government servant (with seal)] (Authorised Signatory of notified Medical Authority) (Name and Seal) Signature/Thumb impression of the person in whose favour disability certificate is issued Note: In case this certificate is issued by a medical authority who is not a government servant, it shall be valid only if countersigned by the Chief Medical Officer of the District The principal rules were published in the Gazette of India vide notification number S.O. 908(E),dated the 31st December, 1996.
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Page 25 of 35 PROFORMA-III-A FORM-V Certificate of Disability (In cases of amputation or complete permanent paralysis of limbs or dwarfism and in cases of blindness) (NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE) Certificate No.: …………………………………………………… Date: ………………………. This is to certify that I have carefully examined Shri/Smt/Kum…………………………………………………………………………………… ……………..son/ wi fe/ daughter of Shri …………………………………………………… Date of Birth ….…………………… Age………… Years, Male/Female………………. (DD/MM/YYYY) Registration No. ………………………………… Permanent Resident of House No. ……………….…………... Ward/Village/Street…………………………..Post
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