INSTITUTE OF PUBLIC ASSISTANCE
(Provedoria), Mala, Panaji-Goa
APPLICATION FOR ASSISTANCE
To,
The Director,
Institute of Public Assistance,
Panaji – Goa
Sub:- Request for:
1. Admission
2. Financial assistance for:
a) Purchase of Medicines
b) Purchase of Spectacles
c) Purchase of Artificial limb / calipers
d) Celebrating Marriage of a girl
e) Being a Stranded visitor
f) Burial or Cremation of deceased family member
( Tick whichever is applicable )
Dear Sir,
I I am in need of assistance for the following reasons.
1 ______________________________________________________________
2 ______________________________________________________________
3 _____________________________________________________________
II Information as would facilitate decision, on my request is furnished below:
Yours faithfully,
(Signature or left hand thumb
impression of the applicant)
1. Full in capital letters:______________________________________________
2. Address in full including ___________________________________________
3. Age:- ___________________________________________________________
III Members of the family living with the applicant
Sr. Name Age Relationship Occupation Income per
No. with the applicant month
1) ________________________________________________________________
2) ________________________________________________________________
3) ________________________________________________________________
4) ________________________________________________________________
5) ________________________________________________________________
6) ________________________________________________________________
7) ________________________________________________________________
8) ________________________________________________________________
9) ________________________________________________________________
10) ________________________________________________________________
IV Members of the family not living with the applicant
1) ________________________________________________________________
2) ________________________________________________________________
3) ________________________________________________________________
4) ________________________________________________________________
(Please score out which is not applicable)
V Herebelow give a brief story of the case indicating special reasons if any requesting assistance.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
VI Income of the applicants family from all sources including that earned by the other members living with the applicant.
Sources Amount earned yearly
Land produced ________________________
House rent ________________________
Service/ Labour _________________________
Other work _________________________
The size of land owned ________________________
Cultivated or on rent ________________________
Land owned ________________________
Land rented ________________________
Income of land terms of Produce
Paddy ____________________ owned land _____________________ rented land
________________________ coconuts ________________________ other produce
VII Are any members of the applicant’s family in position to work ?
Yes / No.
If Yes, then say what kind of work he/she could do to earn a living for the family.
Sr. No. Name Age Kind of work he / she could do
1) ________________________________________________________________
2) ________________________________________________________________
3) ________________________________________________________________
4) ________________________________________________________________
5) ________________________________________________________________
6) ________________________________________________________________
VIII State present monthly income of the family, from all sources which helps the
applicant’s family, to maintain itself Rs. ____________
State approximate minimum monthly expenditure Rs. ___________
IX Did any member of the applicant’s family receive / received any assistance from
the Institute of Public Assistance or other public agencies.
Yes / No.
If Yes, please give the following information
Sr. No. Name and address of Amount received when the agency for the month
1) ________________________________________________________________
2) ________________________________________________________________
3) ________________________________________________________________
Residential Certificate for 15 yrs.
Medical Certificate
Marriage registration certificate
Extension officer certificate
Income Certificate Enclosed / not enclosed
Affidavit
Place:
Date_____________
Signature / thumb impression of the applicant