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.