Scribd
Upload
11K views

CM Relief Fund

The document is a proforma-cum-requisition form seeking financial assistance from the Chief Minister's Relief Fund for medical treatment. It collects information such as the patient's name, address, contact details, details of the hospital and treatment, estimated costs, and any other sources of financial assistance received. The patient is requesting assistance and confirms the information provided is true to the best of their knowledge. Required enclosures include the original hospital estimate and a copy of the ration card or income certificate.

Uploaded by

kumar1309
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
11K views

CM Relief Fund

The document is a proforma-cum-requisition form seeking financial assistance from the Chief Minister's Relief Fund for medical treatment. It collects information such as the patient's name, address, contact details, details of the hospital and treatment, estimated costs, and any other sources of financial assistance received. The patient is requesting assistance and confirms the information provided is true to the best of their knowledge. Required enclosures include the original hospital estimate and a copy of the ration card or income certificate.

Uploaded by

kumar1309
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

PROFORMA-cum-REQUISITION

FOR SEEKING FINANCIAL ASSISTANCE


FOR MEDICAL TREATMENT/EXGRATIA UNDER
“CHIEF MINISTER’s RELIEF FUND” Latest Photo
To

The Hon’ble Chief Minister,


Govt. of Andhra Pradesh,
Hyderabad.

01. Name of the Patient/Beneficiary : __________________________


(with Surname)

02. Father’s/Husband’s Name : __________________________

03. Age : __________________________

04. Permanent Address:

H.No. : __________________________
Street/Village : __________________________
Mandal : __________________________
District : __________________________
Pin Code : __________________________
Phone No. (if any) : __________________________

05. Address for Correspondence:

H.No. : __________________________
Street/Village : __________________________
Mandal : __________________________
District : __________________________
Pin Code : __________________________
Phone No. (if any) : __________________________

06. Name of the Disease/Purpose for seeking : __________________________


exgratia/financial assistance

07. Name & Address of Hospital with Phone : __________________________


& Fax Number __________________________

08. Date of Surgery/Operation : __________________________

09. Estimated/Requested Amount (Hospital : __________________________


estimation in ORIGINAL to be enclosed)

10. Whether any amount was sanctioned under : Source __________Amount:Rs.


CMRF or from any other source

11. Ration Card/Income Certificate : ________________________

The above information given by me is true and correct as per my knowledge and I
request you to sanction financial assistance under CMRF.

Yours faithfully
Place:
Date:
SIGNATURE OF THE PATIENT

Enclosures:
1. Hospital Estimate in original
2. Copy of White Ration Card/Income certificate issued by the MRO.

You might also like