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CMRF Application

This document is a proforma-cum-requisition form seeking financial assistance from the Chief Minister's Relief Fund (CMRF) in Telangana. It collects information such as the patient's name and address, medical details including disease, hospital, and bills, and whether any assistance was previously received. The applicant certifies the information is true and requests CMRF sanction for financial assistance, signing the form along with attaching required documents.

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ismart shankar
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1K views

CMRF Application

This document is a proforma-cum-requisition form seeking financial assistance from the Chief Minister's Relief Fund (CMRF) in Telangana. It collects information such as the patient's name and address, medical details including disease, hospital, and bills, and whether any assistance was previously received. The applicant certifies the information is true and requests CMRF sanction for financial assistance, signing the form along with attaching required documents.

Uploaded by

ismart shankar
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PROFORMA-CUM-REQUISITION

FOR SEEKING FINANCIAL ASSISTANCE/


EXGRATIA UNDER “CHIEF MINISTER’S RELIEF FUND” Latest Photo
(CMRF)
To
The Hon’ble Chief Minister,
Government of Telangana,
HYDERABAD.
01 Name of the Patient / Beneficiary :
. (with Surname expansion)
02 Age :
.
03 Father’s/Husband’s Name :
.
04 Permanent Address: :
.

Pin Code :
Mobile No. :

05 Address for Correspondence :


.

Pin Code :
Mobile No. :

06 Name of the Disease/Purpose for :


. seeking

07 Name & Address of Hospital with :


. Phone & Fax No.

08 Date of Surgery/Operation :
.
09 Incurred Amount :
.
10 Whether any amount was :
. sanctioned under CMRF or from any
other source
11 White Ration Card No. :
.

The above information given by me is true and correct as per my knowledge


and I request you to sanction financial assistance under CMRF.

Yours faithfully,
Place:
Date:
SIGNATURE OF THE PATIENT/
BENEFICIARY

Enclosures:
1. Original in-patient bill 4. Original in-patient detailed bill
2. Original Payment Receipts 5. Original Discharge Summary
3. Copy of Ration Card/Income Certificate (issued by Tahsildar)

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