ar A eet By Gerearad TE io /CHS Card No While in Service 4, Saga Wr ATH /Name of the Applicant. 2. Behl / Category ort oata wor & tert o fed deat ors eg ores ve Form *B* APPLICATION FOR CGHS CARD FOR PENSIONERS OF CENTRAL GOVERNMENT AFI /Pensioners 3, Rear / far ar a ret Sar Pra ge Name of the Department/Service from where retired. 4. of AT Last Pay et YEA /Basic pension . Carre & Are H/in case of pensioners) Set / Pre revised 5, aie Te / Residential Address, 6. GRAY Ho /Telephone Number: 7, 4a até &/ email iD 8. arate @r fet / Date of Superannuation Near io / Mp. 9.. URAR G1 SHRI / Details of Family (ae wre AES ged Gare st sfearst Sa Gt / Please see definition of Family before filling up this column) Si Other (Gat GIA BYPL Specify)) FRA IDate ene FB /Mo mtb oes exo [Wa & ae & Seana SSA | Gr FAA/ Date of ‘BAS FI/ Blood S.No | AH/ oa ta Birth? Group(thtae / ‘Name of Family member | Relationship to (wfrarf / Compulsory) | optional) CGHS Card Holder* ‘eet /self _|__ (# HT SUPT ARTA S SHO GT AMT SILT SAT / Please attach proof of age of persons ied above) 10 ar Gu fort aera } arr fey Ty S a org ox ania F she aad wer ved 8: a /ae ‘Are al the persons whose names are given above are dependant upon you and are residing with your: Yes/No (qua Saar ones ere VET ST AT aE eT Che werd as / Prater veers wa / ue we / ore / rap / fevaterca EI UN Vea va / AH Bore gH ants Hof ) Please attach proof of their staying with you, ike copy of Ration card/Election ID/Pass Port/Identity Card issued by college/schoo/University/Bank Pass Book,etc)2 41, 38 Ry ay way Gad aa)aRar F wets Tees fos avast araeit A) anaes gare ‘Sb am & wy 4 uae fey oP 8 St gear va ser AF ve wterrH Psa eat areal A fera@)Paste one ID card size of Photograph of each member of Family(ineluding self) whose names are proposed to be included as part of your family in the space given below(Names should be written in both the languages): ‘PROS.No... 1+ SFBOS.NO.....sesseseesee. BROS.NO.... -BRHOS.No..- 7 aH a a Name Name Name Name ‘BeOS. No. ce seesss sss SPRIOS.NO.2.e.essescessePHOSNO...ceeseeseseeeeesPHOSNO. ccs cescessssseeen ar a a 7 ‘Name Name Name Name 4 aan tor & fH ga onder Ort H afte AR GRan d awl S ona aees H ae ag acre omen ¢ ah 8 Safa wee Tare thor a aeora Bsa Serr! ae A Efe wea A oraba ere & hk aft data exer varea ahora Bt acora S ay 4 gar wT TTT ea |. aah gre Saha eRe wea thor BH gary afte a ot andl ste serena ste/a seit sian’ at ue ent ag aR faee arg ah arkarg ax wat 31 Tundertake to intimate to CGHS immediately if there is any change in dependency criteria of my family members included in this application form. If I fail to intimate and if the CGHS comes to know of the change then the CGHS facility is liable to be withdrawn by the CGHS and the CGHS and/or appropriate authority will be free to initiate any action against me. dam to & f& Safe wer ees dort Ht yaar Hoag a, F dowownodto ars Ha gar! T undertake to surrender the CGHS Card(s) on ceasing to be eligible for CGHS benefits. % wenfora eer & fe Be onder HA are Gag GT Gila wer wR Siw ae ag ote aig ern wag ai 7g @ aT reat ahd B vel A ag B oie F ews fore Hf fra gI I certify that the information funmnised by me in this application has been verified to be correct and that no information has been concealed or has been misrepresented and I stand by the same GHA / Encl:—sTarha / anPBrat F Wer Xr GT TAT / Proof of Residence/Stay of dependents Br og GT WHIT / Aaa WAIT TA /Proof of age of son/Disability certificate Fwd gy d Saal oes S aio G1 FAT TA / Surrender Certificate of CGHS Card while in service Ahiteit cer sift aot WAIT Ua a arguanflre wfctaTt /Attested copies of PPO & Last Pay CertificateEnclosed DD bearing No.. Branch. andea & SRT / Signature of Applicant Ba 4/To ony Pree a RAEA),9 More sae ecticemecet Weng fee! The Additional Director, CGHS (HQ), 9-Bikaner House Hutments, Shahjahan Road, New Delhi. wiitea eeeneat data aOR kaRed sornqeae) ger waft Lavan TB A/T wre S era Verified- by Authorized Signatory, CGHS (HQ) valid upto . ../ For Rest of Life. arda Wal KARA SA / CCHS Wellness Centre Allotted (* See ETI AT GTY/ to be filled by CGHS) WaT waa / = wih-mgte ae we WE Entitlement General Ward/ Semi Private Ward _/ Private Ward ‘BRIER / SignatureINSTRUCTTIONS UR Ft UTI / Definition of Fa (1) Sff/Husband / eh Wife (tae veh aet First wife only ) * 2) onPre are fer / are AT (aS cate 8, dae aecew afte oneeht area fe aA) Dependent Parents/Step Mother(In case of adoption,only adoptive & not real parents) @) ae are fen at ow S aides vista & Sact we oer! Ifadoptive father has more than one wife, the first wife only. (4) After afar & fed one onfirer are—foer ar ont are agE a afPaferr ey wr Rewcr &; ta ore & dhe food daa We aR ae oT TET a) A female employee has a choice to include either her dependent parents or her dependent parents-in law; option exercise can be changed only once during service. ©) wa Prafatted wat S wes Ey OREM wha ea Te Taal } Re re Ay wea aftafent &1 Children including legally adopted children, step children and children taken as wards subject to the following conditions: @ ‘JaA/Son Sart YS Se A 25 ay Fi any wa wey am ot A vest et) Till he start earning or atttains the age of 25 years whichever is earlier i) | ya /Daughter oar Ye Se A wel ef aM Hany A] aig ain ad), ot af ved Till she start earining or gets | married irrespective of the age limit,whichever may be earlier. Gi) | ya Peet aH ore Ot eng Recit 8 [ey ang ir wet Aisa ar araften)char fe Irrespective of age limit, Ara afta & Son suffering from any permanent disability of any kind(Physical or mental) as defined below Gs) entre sermaar/ aera ar on GR | aE og ei aT Baer / fue asftrat ate onfirt Irrespective of age limit fata / serge oR ar ot oft 8 arent / Rear ay Dependent divorced/abandoned or separated from their husband/widowed daughers and dependent unmarried/ divorced abandoned or separated from their husband/widowed sisters. @) | aie ae ae are eM @ ag aa Dependent Minor brother(s) Upto the age of becoming a major, 25 eG OW fmaiT ya S fore Sala aOR Ged aha A GAY ore wey OY Qa wr wierd ant at Reciren sr waTI—Ta ve wT For the purpose of availing CGHS facility for a disabled sons above 25 years, Please attach a cocy of the certificate of disability issued by the competent authority5 Reever Racin, cafe ora, otrert FH epeT cn gel areal, 1995(1996 4) ener 2(1) A Prater Reeve ery tp ATE oe a TE ‘Disability’: will be As DEFIND IN SECTION 2(\) OF THE PERSONS WITH DISABILITIES (EQUAL OPPORTUNITIES PROTECTION OF RIGHTS AND FULL PARTICIPATION) ACT, 1995 (NO: | of 1996) WHICH IS REPRODUCED BELOW: faeeire or ste “DISABILITY MEANS () urs /BLINDNESS (i) &A fe /Low vision (i, S7eIRRa BW, LEPROCY CURED (V) rT Fe Ta 8/ HEARING IMPAIRMENT (V) ert fire # wfSaTg /LOCOMOTOTR DISABILITY (VI) Araftras SaSaT/ MENTAL RETARDATION (vil) Peart ater / MENTAL ILLNESS (vip SPH / Dependency: uRae & wee (fa / aero wreax\ferrat ws ara 3500 /-+ weg aa S HAS Wret anf wars ony oie Gt area: Sala ERO eared dior reel B arr wet FI Members of family (other then spouse)whose income is ess than Rs.3500/-+DA per month are treated as dependents and are normally residing with CGHS beneficiary. Prafettnr cera ders fey Ty | ‘The Following Documents are to be enclosed: 6) ararita wart/antrt or frer-rem ors / Rafer wear va / ore ae /area, eae axafterea ERI oie cea wa/ aa oA gH onfe ay ufa) Proof of Residence /Stay of dependents- (copy of Ration Card/ Election 1D/Pass Por! Identity Card issued by College/ Schoo/University/Bank Pass Book,etc.) 2) Ja FF ay BI FAM Proof of age of son @) Fer ae grr wre fleseriren wa —os BY Tenfie wae anfr ya Bt oy 25 OT See afew #) Attested copy of Disability certificate isssued by Competent Authority( in case of dependent son aged 25 and above) tery 3 fora oh vech ay Safa wer ered thor we & fey ones ar ez, Praferfead often aearta enfee: For Pensioners applying for CGHS card for the First time the following Additional Documents are required: @) Sa arse Sate eer eared ahr we es ar ATT Ta (5) Surrender Certificate of CGHS Card while in service. ars arene onde / fea Aes ATT a A eater Attested copy of PPO& Last Pay Certificate Say ama sires “Aes wd Gem siftend, daha weer waned shoriag feat” } ary fect ¥ Qa dm gexec (ftyfaa Se) grr ort fen ora afee! Contribution by Pensioners should be made by Bank Draft (Scheduled Banks) payable in Dethi in favour of Pay & Accounts Officer CGHS, Delhi,