Cm Relief Fund
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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 CMRF or from any other source
: Source __________Amount:Rs.
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.
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 CMRF or from any other source
: Source __________Amount:Rs.
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.
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