Form of application for financial assistance from

Chief Ministers Distress Relief fund

1. Name and address of the applicant

2. Occupation

3. Property details and Income from Property

4. Details of family income

5. Details of family members who are working

and their income

6. Annual income of the family

7. Nature of accident / disease

8. Name of the person suffering from disease/

met accident

9. Whether the patient is a major

10. Date of accident /date of starting illness/

whether still under continuous treatment/
period up to which treatment is to be continued

11. Date of loss sustained and volume of loss

12. Whether eligible for F.A/Compensation from

any other scheme If eligible under what scheme.

13. Any financial assistance or compensation received

previously and if received details to be furnished.

I declare that the above facts are true to the best of my knowledge and faith.

Signature of the applicant.

Place :

Date :