Appendix ‘B’
QUESTIONNAIRE FOR FINANCIAL ASSISTANCE FROM
SPECIAL FUND FOR EX-SERVICEMEN/WIDOWS
1. Identity Card No. _______________________________(issued by Dept. of Sainik Welfare)
2. No. ____________ Rank ____________ Name ___________________________________
3. Arms/Services ___________________
4. Date of Birth
____________________________
5. Date of Enrolment ____________________
6. Date of Discharge
_____________________
7. Date of Discharge (if deceased) : _______________________________
8. Reasons for leaving Service
___________________________________________________
9. Full Address
_______________________________________________________________
________________________________________________________________________
____
10. Service Pension including DA : _________________________________________
11. Name of Bank and Address (from where pension is drawing)
_________________________
________________________________________________________________________
____
12. Account Number : __________________________
13. Details of Widow (if applicable)
(a) I/Card No. _____________________ Name of Widow :
_________________________
Date of Birth ____________________
(b) Address :
____________________________________________________________
(c) Family Pension Including DA : Rs.
_________________________________________
14. Present occupation of Ex-Servicemen/Widow :
____________________________________
15. If employed : Name of Dept./Office :
___________________________________________
16. Other Income from
(a) House/Plot ____________________ Sq. Mts. Rental income
_________________ p.m.
(b) Agriculture Area _______________ Sq. Mts. Income
_______________________ p.m.
(c) Type of self-employment ___________________ income
____________________ p.m.
(d) Pension from other sources
_______________________________________________
17. Name of the Bank and Address :
_______________________________________________
_________________________________________ Account No.
_____________________
18. Details of Dependents (as applicable)
Name Relation- *DOB/Age Occupation Salary p.m.
Ship
1.
2.
3.
4.
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19. Nature of problem (in brief) alongwith Xerox copy of relevant documents like bills/income Certificate/medical data as required.
______________________________________________________________________________
________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
20. Details of Assistance Received
Year Amount From To
(a) Monthly assistance from Dept
of Sainik Welfare, Goa. _______ ________ ________
________
(b) Provedoria Assistance _______ ________ ________
________
(c) Daughter’s Marriage _______ ________ ________
________
(d) Funeral Expenses _______ ________ ________
________
(e) Stipend _______ ________ ________
________
(f) Medical Reimbursement _______ ________ ________
________
(g) Any other Assistance from BF/SF _______ ________ ________
________
(h) Spot payment _______ ________ ________________
I hereby solemnly declare that ass information given above is true to the best of my knowledge and that nothing has been concealed. I understand that I shall forfeit any claim for any assistance from Department of Sainik Welfare, Goa in the future if found incorrect.
Signature of the ESM/Widow ___________
Place : Name of ESM/Widow : ________________
Date : RSB GOA I/Card No. _________________
1. Questionnaire form be submitted by the ESM/Widow alongwith the under mentioned documents for consideration:-
(a) Forwarding letter with brief details
(b) Domicile certificate of the Ex-Servicemen/Widows if they are domiciled in the State of Goa or in case of domicile certificate has already been produced to this Department previously, then the residence certificate from the concerned Panchayat/ Municipality be produced alongwith the application.
(c) In case, if Ex-servicemen is of Goan origin, the proof thereof.
(d) The financial assistance initially provided for one year and it should be renewed every year. The renewal application should be submitted to this Department two months before expiry of financial assistance.
2. Incomplete applications/without supporting documents will be rejected without further correspondence.