gbtk;-m ghu;f;f tpjp-16 (1) khw;Wj;jpwdhsp egUf;F fhg;ghsiu epakpg;gjw;fhf khw;Wj;;;jpwdhspapd; cwtpdu; my;yJ xU gjpT ngw;w mikg;gplk; ,Ue;J cs;@u; FOtpw;F tpz;zg;gpg;gjw;fhd gbtk;

mDg;Geu;:

Njjp:

ngWeu;: khtl;l Ml;rpau; kw;Wk; jiytu;> cs;@u; FO> Njrpa mwf;fl;lis> GJf;Nfhl;il khtl;lk;. Iah/mk;kh> .................................................... vd;gtu; khw;Wj;jpwdhsp egu;. mtUf;Fk; mtUila nrhj;Jf;Fk; xU fhg;ghsu; %yk; ghJfhg;G Njitg;gLfpwJ. .................................... vd;gtiu ....................................... vd;gtUf;Fk; mtuJ nrhj;Jf;Fk; fhg;ghshuhf epakpf;Fk;gb Ntz;LfpNwhk;. NkYk; tpguq;fis ,q;F ,izj;Js;Nshk;. tpiutpy; KbT NfhUfpNwhk;. ..................................... vd;gtupd; khw;Wj;jpwdhspf;fhd rhd;wpjo;/ Njrpa milahs ml;ilapd; efypid ..................................... vd;gtuplk; ngw;W ,j;Jld; ,izj;Js;Nshk;. cq;fs; cz;ikAs;s>

rhl;rpfs;:

mq;fPfupf;fg;gl;ltupd; ifnaOj;J

1-tJ rhl;rp:

ngau;: .............................................. ......... gjtp: ........................................................

2-tJ rhl;rp:

mYtyf Kj;jpiu: ...............................

fhg;ghsuhf epakpf;fg;gl Ntz;batupd; rk;kjk;. .......................................... vd;gtupd; egUf;Fk; cilikf;Fk; fhg;ghshuhf ,Uf;f rk;kjpf;fpNwd;. vdJ flikfis rupahf epiwNtw;WNtd;.

ifnaOj;J

Njjp:

ngau;

Nkw;nrhd;d Kbtpw;F fhg;ghsupd; rk;kjk; ........................................... vd;gtupd; fhg;ghsuhf ....................................... vd;gtiu epakpf;Fk; Kbtpw;F cld;gLfpNwd;.

ifnaOj;J

Njjp:

ngau;

khw;Wj;jpwdhspapd; ngau; Name of Person with Disability (PWD)* gpwe;j Njjp Date of Birth* taJ Age ghypdk; Mz; Gender* jpUkz epiy jdpau; Marital Status* je;ij ngau; Father’s Name* jhahu; ngau; Mother’s Name* Kftup Address*

: : : ngz; : Male

Female kzkhdtu;

: Single

Married

: : :

khepyk; State* khtl;lk; District* gpd;NfhL Pincode* khw;Wj;jpwdhspapd; Mjhu; vz; PWD Aadhaar Card No.

: : : :

(Mjhu; vz; ,Ue;jhy; vOjTk;) Enter Aadhaar Card no if available midj;J * Fwpapl;l tpguq;fSk; epug;gg;glNtz;Lk;. Please Fill All * Marked Mandatory Fields. khw;Wj;jpwdhspapd; Mtz tpguq;fs;/ PWD DOCUMENT DETAILS khw;Wj;jpwdhspapd; ,Ug;gplk; Residence of PWD*

:

khw;Wj;jpwdpd; tif Disability Type* : rjtPjk; Percentage % * : khw;Wj;jpwdhspf;fhd rhd;W toq;fpa mjpfhup Issuing Authority of Disability Certificate *

:

The Disability Certificate should be from any Recognized Government Hospital . rhd;W toq;fpa mjpfhupapd; ngau; Issuing Authority Name

gjtpapd; ngau; Designation/

Kftup Address/

njhlu;G vz;. Contact Number/

khw;Wj;jpwdhspapd; nrhj;J tpguk; PERSION WITH DISABILITY ASSETS DETAILS khw;Wj;jpwdhspapd; ngaupypUf;Fk; mirAk; nrhj;Jf;fspd; tpguk; Details of Movable Property on Which PWD has Share * : khw;Wj;jpwdhspapd; ngaupypUf;Fk; mirahr; nrhj;Jf;fspd; tpguk; Details of Immovable Property on Which PWD has Share as per format * : Gy vz; Survey No./

fpuhkk;/ efuk; Village/ Town

mirahr;nrhj;jpd; msT tpguk; Measurement of Immovable Property

,ju tpguq;fs; Other Information

,izf;fg;gl Ntz;ba Mtzq;fs;/Documents to be attached: 1. khw;Wj;jpwdhspapd; Njrpa milahs ml;il efy;> FLk;g ml;il efy;> Mjhu; ml;il efy; kw;Wk; ,Ug;gplr;rhd;W efy;. Copies of PWD’s National ID Card, Ration Card & Residential Certificate*. 2. khw;Wj;jpwdhspapd; mirAk; nrhj;J> mirahr; nrhj;J ,Ue;jhy; mjd; Mtzq;fs; efy;. Document Copies of PWD’s Movable and Immovable Properties*. 3. fhg;ghsupd; FLk;g ml;il efy;> Mjhu; ml;il efy;> kw;Wk; ,Ug;gplr; rhd;W efy;. Properties of Guardian’s Ration Card, Aadhaar Card & Residential Certificate Copies*. 4. fhg;ghsuhf epakpg;gjw;fhd mDkjpr; rhd;W efy;/ mDkjpj;jjw;fhd rhd;W efy;. Proposed Guardian Proof of Consent & Existing Consent Certificate*. 5. tpz;;zg;gjhuupd; FLk;g ml;il efy;> Mjhu; ml;il efy; kw;Wk; ,Ug;gplr; rhd;W efy;. Application Ration Card, Aadhaar Card & Residential Certificate Copies*. 6. Kjy; rhl;rp kw;Wk; ,uz;lhk; rhl;rpfspd; FLk;g ml;il kw;Wk; Mjhu; ml;il efy;. First Witness and Second witness Ration Card & Aadhaar Card Copies.

fhg;ghsu; gw;wpa tpguk;/ GUARDIAN DETAILS

fhg;ghsu; Proposed Guardian *

jdpegu; my;yJ ,UtUk; epWtdk; : Individual or Both Guardian

Organization

fhg;ghsu; ngw;Nwhuhf ,Ug;gpd;> ,Utupd; ngaUk; Fwpg;gplg;glNtz;Lk;. In case the proposed guardian is a parent, then the name of the other parent most also be included. jdpegu; my;yJ ,Utupd; tpguq;fs; Individual or Both Guardian’s Detail. fhg;ghsupd; ngau; Guardian’s Name*. kw;nwhU ngw;Nwhupd; ngau; Guardian’s Name (Name of other Parent) Kftup Address*

: : : :

khepyk; State* : khtl;lk; District* : gpd;NfhL Pincode* : AIb/ Mjhu; ml;il vz; UID/ Aadhaar Card No : ,nkapy; Ib Email ID* : NtW ,nkapy; Ib ,Ue;jhy; Fwpg;gpL If any other Email please specify : fhg;ghsuhf epakpg;gjw;fhd mDkjp cs;sjh? Consent of the person proposed to be appointed Guardian* : Yes No gioa fhg;ghsupd; mDkjp VJk; cs;sjh? Consent of the existing Guardian, If any* : Yes No fhg;ghsuhf jw;rkak; tpz;zg;gpj;jpUg;gtu; Undertaking by the applicant that the Proposed Guardian is: * 1. xU ,e;jpa Fbkfd; A Citizen of India 2. kdepiy ghjpf;fg;gl;ltNuh my;yJ mjw;fhf jw;rkak; rpfpr;ir vLg;gtNuh my;y If not of unsound mind or is currently undergoing treatment for mental illness.

tpz;zg;gjhuupd; tpguk;/ APPLICANT DETAILS tpz;zg;gjhuupd; ngau; Name of the Applicant* Kftup Address*

: :

khepyk; State : khtl;lk; District* : gpd;NfhL Pincode* : AIb/ Mjhu; vz; UID/ Aadhaar No : tpz;zg;gjhuupd; cwTKiw ngw;Nwhu; cwtpdu; gjpT ngw;w mikg;G Relationship of PWD with Applicant : Parent Relative Registered Organization cwtpdu; vd;why; (,uj;j rk;ge;jk;/jj;njLj;jy;/jpUkzk;) Relative means (related by Blood, Adaption, Marriage) ngw;Nwhu; cwtpdu; gjpT ngw;w mikg;G

fhg;ghsupd; cwTKiw Relationship of PWD with Proposed Guardian * : Parent Relative Registered Organization ve;j khjpupahd fhg;Gj;jd;ik Njit vd Fwpg;gplTk; Tick the Obligations for which Guardianship is to be given* guhkupg;G kw;Wk; ,y;y ftdpg;G mirahr; nrhj;Jf;fspd; Nkyhz;ik Maintanance and Residential Care Management of immovable property mirAk; nrhj;Jf;fspd; Nkyhz;ik ,d;Dk; gpw Management of movable property any other? Kjy; rhl;rpapd; ngau; First Witness Name* Kftup Address* njhlu;G vz; Contact No.* AIb/ Mjhu; ml;il vz; UID/ Aadhaar Card No. ,uz;lhtJ rhl;rpapd; ngau; Second Witness Name * Kftup Address *

: :

: :

: :

njhlu;G vz; Contact No *

:

AIb/ Mjhu; ml;il vz; UID/ Aadhaar Card No.

: nuNdrhd;];

‘kyu;r;rp’ kdtsu;r;rp Fd;wpa khw;Wj;jpwdhspfs; jq;Fk; tpLjpAld; $ba rpwg;G gs;sp kw;Wk; Mz;fSf;fhd njhopw;gapw;rp ikak;.