Form for

 


figures: - ____________________ perce☝nt 

In words:- 

______________________________________________________________ percent 

2. This condition is progressive/non-progressive/likely to improve/not likely to 

improve. 

3. Reassessment of disability is: 

(i) not necessary, 

Or 

(ii) is recommended / after __________ years __________ months, and therefore this 

certificate shall be valid till (DD / MM / YY) ____ ____ ____ 

@ - e.g. Left/Right/both arms/legs 

# - e.g. Single eye / both eyes 

£ - e.g. Left / Right / both ears 

4. The applicant has submitted the following documents as proof of residence :- 

Nature of Document Date of Issue Details of authority issuing 

certificate 

5. Signature and Seal of the Medical Authority 

Name and seal of Member Name and seal of Member Name and seal of Chairperson 

Signature/Thum

b impression of 

the person in 

whose favour 

disability 

certificate is 

issued.

FORM - III

Disability Certificate

(In cases other than those mentioned in Form I and II)

(Prescribed proforma subject to amendment from time to time)

(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Certificate No.: Date:

This is to certify that I have carefully examined Shri/Smt./Kum.

_____________________________________________________________

son/wife/daughter of Shri ____________________________________________ Date

of Birth (DD / MM / YY) ____ ____ ____

Age________ years, male/female __________Registration No.

__________________________

permanent resident of House No.______________________ Ward / Village / Street

________________________________________ Post Office

___________________________________District __________ State ____________,

whose photograph is affixed above, and am satisfied that he / she is a Case

of______________________ disability. His/her extent of percentage physical

impairment / disability has been evaluated as per guidelines (to be specified) and is

shown against the relevant

the relevant disability in the table below:

No. Disability Affected Part of

Body

Diagnosis Permanent physical

impairment/mental

disability (in %)

1 Locomotor disability @

2 Low vision #

3 Blindness Both Eyes

4 Hearing impairment £

5 Mental retardation X

6 Mental-illness X

(Please strike out the disabilities which are not applicable.)

2. The above condition is progressive/non-progressive/likely to improve/not likely to

improve.

3. Reassessment of disability is:

Certificate for person with specified disability covered under the definition of Section 2

(s) of the RPwD Act, 2016 but not covered under the definition of Section 2(r) of the

said Act, i.e. persons having less than 40% disability and having difficulty in writing.

1. This is to certify that, we have examined Mr/Ms/Mrs ………………………………………… (name

of the candidate), S/o / D/o ………………………………………, a resident of

………...……………………… (Vill/PO/PS/District/State), aged ………………… yrs, a person with

……………………………… (nature of disability/condition), and to state that he/she has

limitation which hampers his/her writing capability owing to his/her above

condition, He / She requires support of scribe for writing the examination.

2. The above candidate uses aids and assistive device such as prosthetics & orthotics,

hearing aid (name to be specified) which is / are essential for the candidate to

appear at the examination with the assistance of scribe.

3. This certificate is issued only for the purpose of appearing in written examinations

conducted by recruitment agencies as well as academic institutions and is valid upto

______________ (it is valid for maximum period of six months or less as may be

certified by the medical authority).

Signature of Medical Authority

(Signature &

Name)

(Signature &

Name)

(Signature &

Name)

(Signature &

Name)

(Signature &

Name)

Orthopedic/

PMR specialist

Clinical

Psychologist/

Rehabilitation

Psychologist/

Psychiatrist/

Special

Educator

Neurologist (if

available)

Occupational

therapist (if

available)

Other Expert,

as nominated

by the

Chairperson (if

any)

(Signature & Name)

Chief Medical Officer / Civil Surgeon / Chief District Medical Officer …………………………………

Chairperson

 Name of Government Hospital / Health Care Centre with Seal


Government of ----------------------------------- 

(Name & Address of the authority issuing the certificate) 

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY THE ECONOMICALLY WEAKER 

SECTIONS 

Certificate No. ____________________ 

Date:_____________________ 

VALID FOR THE YEAR ____________ 

This is to certify that Sri/Smt./ Kumari 

___________________________son/daughter/wife of 

___________________________permanent resident of 

_____________________Village/Street _________________Post Office 

_______________ District in the State/ Union Territory_________________ Pin 

Code_______________ whose photograph is attested below belongs to Economically 

Weaker Sections, since the gross annual income* of his/her family** is below Rs. 8 lakh 

(Rupees Eight Lakh only) for the financial year ___________. His/her family does not 

own or possess any of the following assets*** 

i. 5 acres of agricultural land and above; 

ii. Residential flat of 1000 sq. ft. and above; 

iii. Residential plot of 100 sq. yards and above in notified municipalities; 

iv. Residential plot of 200 sq. yards and above in areas other than the notified 

municipalities. 

2. Shri/Smt./Kumari _______________________ belongs to the ________ caste which 

is not recognized as a Scheduled Caste. Scheduled Tribe and Other Backward Classes 

(Central List) 

 Signature with seal of office_________________ 

 

Name__________________________ 

 

Designation__________________ 

Recent Passport 

size photograph of 

the applicant 

*Note 1: Income covered all sources i.e. salary, agriculture, business, profession etc. 

**Note 2: The term “Family” for this purpose include the person, who seeks benefit of 

reservation, his/her parents and siblings below the age of 18 years as also his/her spouse 

and children not below the age of 18 years. 

***Note 3: The property held by a “Family” in different locations or different 

places/cities have been clubbed while applying the land or property holding test to 

determine EWS status.

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