No-1 , Ramachandra Nagar,

SRI RAMACHANDRA Porur , Chennai - 600116

Ph. : 24768027, 31 - 33
MEDICAL CENTRE Fax : 091 - 44 - 24765895

Dr. Henry Raj MS (Ortho), DNB (PMR) Dr. Judy Bowden MD (PMR)
Dr. Udhaya Kumar , DPMR , MD (PMR) Dr. Robert Thomson, DNB , MNAMS(PMR)

FORM NO.10-I
INCOME - TAX RULES , 1997 EDITION , P.I. 364

Insertion of Form No.10 – I

FORM NO. 10 – I
( See Rule 11DD )

1. Name of the Patient : SIVARAJ RAO.B

2. Address : NO.12,2nd Cross Street,

Mathur , Chennai - 66

3. Name and details of disease ailment : TRAUMATIC TETRAPLEGIA

(Please see Rule 11DD) Disablity more than 80%

4. The date of commencement of treatment : Date of Injury. 14-NOV-2012

Date of Admission.RMC 03-DEC-2012

5. Name , address, Registration No.of the : Dr.P.S Rajkumar , Dept.of PMR,

Prescribed Authority ( See Rule 11DD(2)) RMC , Chennai.Reg No.63182

Verification

I certify that the information that above is true to the best of my knowledge and the patient is
suffering from chronic and protracted disease as defined in section 80 DDB of Income- Tax
Act, 1961 read with rule 11DD of Income - Tax Rules, 1962

AR
Dr. P.S RAJKUM
MR )
M.S., D.N.B (P
nt
Senior Consulta
ci ne & Rehabilitation
al Medi
Dept.of Physci a Medical Cent
re
Sri Ramachandr - 60 01 16
i
Porur , Chenna
Reg.No. 63182