સૈનિક કલ્યાણ અને પુનર્વસવાટ :

FINANCIAL CONDITION REPORT FORM

Rating :

FINANCIAL CONDITION REPORT FORM

(Particulars of ex-serviceman and his family for grant of financial assistance from Raksha Mantri’s Discretionary Fund)

1. Name of the Applicant/ex-Serviceman _______________________________________________________________

2. Service No. ________________________________________Rank ______________________________________

3. Address: Vill: _______________________________________Post Office __________________________________

Tehsil: ________________________Distt ______________________________Pin ____________________________

4. Date of (a) Enrolment ________________________________(b) Discharge ________________________________

5. Reasons for discharge ___________________________________________________________________________
(As given in Discharge Certificate)

6. Character at the time of discharge __________________________________________________________________

7. Date of Birth/Death of ex-serviceman _______________________________________________________________

8. Particulars of family members:
(Details of all the children to be covered)

Ser No	Name	Relationship with the ex-serviceman	Whether dependent/ independent	Age	Occupation monthly income

9. (a) Was/is the ex-serviceman in receipt of pension -	YES/NO.

(b) If so, nature of pension -	Service pension/ Family pension/
	Disability pension/Civil pension
(c) Total emoluments ( Basic +DA + others) Rs.	_____________________________________________

(d) Annual income from other sources: Rs. (Such as land, rented houses, others)	_____________________________________________

(e) Whether in receipt of second pension
(from re-employment),if yes, state amount: Rs.	_____________________________________________

10. If re-employed, income there from: Rs. ______________________________________________________________

11. Details of Financial Assistance received in past from KSB/RSB/ZSB

(Name of grant _________________________________Amount _____________________Year _________________)

12. Assistance to old and infirm Ex-serviceman/widow (Monthly Grant of Rs.2000/- pm for two years)

(a) Whether the ESM/dependent is in receipt of old age/WW-II pension/ financial assistance given by the state Govt. under various State Govt. schemes.

(b) If not eligible for old age/ WW-II pension/ financial assistance under any State Govt. schemes, the reasons thereof: _______________________________________________________________

(c) Whether the Certificate from Secy. ZSB is enclosed stating that the ESM/ Widow is above the 65 years of age and is not in receipt of any type of Financial Assistance/Pension from any other agency: _______________________________________

Eligibility Conditions:
For Non-Pensioners only and not in receipt of any kind of Financial Assistance from any agency.

13. Assistance to old and infirm Ex-serviceman/Widow(Penury Grant of Rs.30,000/-)

(a) Whether the ESM/Widow is in receipt of old age/WW-II Pension/ financial assistance given by the State Govt. under various State Govt. schemes

(b) If not eligible for old age/ WW-II pension/ financial assistance under any State Govt. schemes, the reasons thereof: ______________________________________________________________________________

Eligibility Conditions: For Non-Pensioners only.

14. Assistance to old and infirm Ex-serviceman/Widow(Penury Grant of Rs.500/-pm)

(a) Whether the ESM/Widow is in receipt of old age/WW-II Pension/ financial assistance given by the State Govt. under various State Govt. schemes

(b) If not eligible for old age/ WW-II pension/ financial assistance under any State Govt. schemes, the reasons thereof: _____________________________________________________________________________________

(c) Whether the Certificate from Old Age Home/Gram Pradhan certifying that the ESM/Widow is staying at Old Age Home/Own house has been attached .________________________________________________________________

Eligibility Conditions:
For Non-Pensioners only of above 70 years of age (for old age home)and above 75 years of age (staying at own house).

15. Assistance to Orphan Children of Ex-serviceman with 100% disability(Penury Grant of Rs.500/-pm)

(a) Whether the certificate by Military/Civil Hospital confirming 100% disability of Child/ Children is attached _____________________________________________________________

(b) Whether the Death Certificate of Parents are attached ___________________________________________________

Eligibility Conditions:
For Orphan Children with 100% disability only.

16. Financial Assistance for Daughters Marriage /Widow Remarriage(Rs.16,000/-)

(a) Actual date of solemnization: ______________________________________________________________________

(b) Whether confirmation certificate/Marriage Invitation Card is attached: ________________________________________

Eligibility Conditions:
upto two daughters only. Maximum Gross Pension should be upto Rs.3000/- for ESM and Rs.Rs.3500/-for Widows.

17. Medical Grant( Upto a maximum of Rs.30,000/-only).

(a) Whether the applicant approached MH/Govt. Hospital for treatment, if so, reference may be enclosed. If not, the reasons thereof _____________________________________________________________________________

(b) Whether original medical bills/receipts have been countersigned by the competent medical authority and summary of medical bills/Hospital admission/discharge certificate enclosed ________________________________________________.

(c)
An undertaking will have to be given by the applicant availing the medical assistance/grant from RMDF/AFFDF as follows :-

"I (Name) ________________________ Rank ___________________ No _______________ have clearly understood the provisions/guidelines of RMDF/AFFDF that these are not reimbursement scheme and are merely ex-gratia grants for medical assistance/grants to the maximum amount of Rs. 30,000/- and Rs. 1.00 lakh respectively and I will not resort to any litigation in any court to claim in the reimbursement of the treatment."

Eligibility Conditions
: Maximum Gross pension should not be more than Rs. 3000/- for ESM and Rs. 3500/- for widows and should not be member of ECHS.

18. Grant for Children Education for wards of ESM/Widows upto XII Std(Rs. 200/- pm for boys & Rs. 400/- pm for girls, per child for maximum of Two children).

(a) Particulars of child/children from whom the education grant is applied for :-

Sl No	Name	Name of School	Class in which studying	Years of session

(b) Whether certificate obtained from the concerned school confirming date of birth/ Mark sheet and above details have been enclosed :-_________________________________________________________________________

Eligibility Conditions
: Maximum Gross Pension should be upto Rs. 3000/- for ESM and Rs. 3500/- for widows.

19. Grant for Children Education for Graduation for girls only(Rs.600/-per month)

(a) Particulars of girls child/children from whom the education grant is applied for:-

Sl No	Name	Name of College/Institute	Year of Graduation	Session

(b) Whether certificate obtained from the concerned College/Institute confirming date of birth/ Mark sheet and above details have been enclosed :-______________________________________________________________________________

Eligibility Conditions
: Maximum Gross Pension should be upto Rs. 3000/- for ESM and Rs. 3500/- for widows.

20. Grant for Children joining Defence Officers Training Institute like NDA/IMA for the duration of the Training(Rs.1000/-per month)

(a) Particulars of child from whom the grant is applied for:-

Sl No

Name

Name of Defence Institute

Year of Training

Duration of Training

(b) Whether certificate obtained from the concerned Defence Institute confirming that the candidate is admitted as a Cadet has been enclosed :-__________________________________________________________________________________

Eligibility Conditions
: Maximum Gross Pension should be upto Rs. 3000/- for ESM and Rs. 3500/- for widows.

21. Grant of House Repair for ESM/Widows in Penury or 100% Disabled ESM (upto a maximum of Rs.20,000/-).

(a) Cause of damage: ______________________________________________________________________________

(b) Whether certificate obtained from Gram Pradhan is enclosed: ______________________________________________

(c) Whether any relief has been given by the State Govt./other authority ? if not, reasons thereof:- _______________________________________________________________________________________________

Eligibility Conditions
: Only if the damage is due to natural calamities like flood, Earthquake, Fire and any other. The Maximum Gross Pension should be upto Rs. 3000/- for ESM and Rs. 3500/- for widows.

22. Grant of House Repair for Orphan Daughter(upto a maximum of Rs.20,000/- for one daughter only).

(a) Cause of damage: ______________________________________________________________________________

(b) Whether certificate obtained from Gram Pradhan is enclosed: ______________________________________________

(c) Whether any relief has been given by the State Govt./other authority ? if not, reasons thereof:- _____________________________________________________________________________________________

(d) Whether the Death Certificate of Parents are attached ___________________________________________________

(e) Whether the Dependency Certificate by ZSB is attached. _________________________________________________

Eligibility Conditions
: For one Orphan Daughter only (PBORs & Officers).

23. Funeral Allowance to the Widows of ESM (Rs.5,000/-one time).

(a) Date of death: _________________________________________________________________________________

(b) Whether Death Certificate is enclosed: _______________________________________________________________

(c) Whether any relief has been given by the State Govt./other authority ? if not, reasons thereof:- _______________________________________________________________________________________________

Eligibility Conditions
: Maximum Gross Pension should be upto Rs. 3000/- and should be apply within three months of Death of ESM.

24. Financial Assistance to the Orphan Daughters of ESM(PBOR & Officers) (Rs.1000/-per month upto marriage or 21 Years whichever is earlier).

(a) Whether Death Certificate is enclosed: _______________________________________________________________

(b) Whether the Dependency Certificate is enclosed: _______________________________________________________

(c) Whether any relief has been given by the State Govt./other authority ? if not, reasons thereof:- _____________________________________________________________________________________________

Eligibility Conditions
: For one Orphan Daughters only.

25.
Declaration by the applicant, "I understand that this is an ex-gratia grant only and I have no legal rights on the amounts requested for. Further I understand that only one of the above grants is applicable to me and I will not ask for any further grants out of RMDF".

(Signature/Thumb impression of the applicant)

26. Specific recommendation of Secretary, Zila Sainik Board: ________________________________________________

_______________________________________________________________________________________________

Date :	Signature:

Office Seal:	Designation:

Note:- The case of financial assistance from RMDF is processed on the basis of information/particulars furnished in the FCR by the ZSB. The Zila Sainik Welfare Officers should ensure that information/particulars given in the form are correct. Copy of the Discharge Certificate and ESM Identity card should be attested by Zila Sainik Welfare Officer.

/copy/

Tele: 26188098

Government of India
Ministry of Defence
Kendriya Sainik Board
West Block-IV, Wing-V
RK Puram, New Delhi-66

189/KSB/B/RMDF/Gen/07

Dt. 04 Jul 07

Director/Secy
Rajya Sainik Board
Gujarat

FORWARDING OF NEW REVISED FINANCIAL CONDITION REPORT

1. The New revised Financial Condition Report (FCR) is enclosed herewith for your perusal and information please.

2. It is requested to vet the cases at your end so as to ensure no repeated claims of same nature by a particular ESM are forwarded to this office.

Sd/- x x x

(HS Virdi)
Jt Dir (Trg & Sch)
For Secretary

Encl: As above