GOVERNMENT OF RAJASTHAN

DEPARTMENT OF MEDICAL AND HEALTH

Disability Certificate (Form-IV)
Certificate No.SAP/2023/1549941 Date:22-10-2023

This is to certify that I have carefully examined Shri/Smt./Kum. ANIL KUMAR son/
wife/ daughter of Shri GUGAN RAM Date of Birth(DD / MM / YYYY) 15/07/1986
Age 37 years, MALE Registration No SAP/2023/1549941 Permanent resident of
HouseNo. SOLANA Street BADI SCHOOL KE PICHE VALI GALI Area
SOLANA Landmark WARD NO05 Village SOLANA Grampanchayat
SOLANA Panchayatsamiti CHIRAWA Tehsil CHIRAWA District
JHUNJHUNU State RAJASTHAN whose Photograph is affixed and am satisfied
that:

(A) he is a case of Multiple Disability. His extent of permanent physical impairment/ disability has
been evaluated as per guidelines (to be specified) for the disabilities ticked below, and is
shown against the relevant disability in the table below:
Affected part Diagnos Permanent physical impairment/
S.No Disability
of body is mental disability(in %)
LOCOMOTOR ACCIDN
1. LEFT HAND 65
DISABILITY ET

(B) In the light of the above, his over all permanent physical impairment as per guidelines (to be
spedified), is as follows :-
1. In figures :- 65 Percent
In words :- Sixty Five Percent
2. This above condition is NON-PROGRESSIVE not likely to improved .
3. Reassessment of disability is:
(i) not necessary , and therefore this certificate shall be valid PERMANENT

Signature Not Verified

Digitally signed by Raj Kumar Dangi
Designation : CM&HO JHUNJHUNU
Date: 2023.10.22 21:50:57 IST
Reason: Approved
Location: JHUNJHUNU

Note: This is a digitally signed certificate and does not required any physical signature.