ANNEXURE 7 (I)
FORM NO. 10-IA [See Sub-rule (2) of rule 11A]
Certificate of the medical authority for certifying ‘person with disability’, ‘severe disability’, ‘autism’, ‘cerebral palsy’ and ‘multiple disability’ for purpose of section 80DD and section 80U
Certificate No...... Date:...... This is to certify that Shri/Smt./Ms...... son/daughter of Shri ...... , age ...... years ...... male/female* residing at...... , Registration No...... is a person with disability/severe disability* suffering from autism/cerebral palsy/multiple disability*. 2. This condition is progressive/non-progressive/likely to improve/not likely to improve*. 3. Reassessment is recommended/not recommended after a period of ...... months/years*.
Sd/- (Neurologist/Pediatric Neurologist/Civil Surgeon/Chief Medical Officer*)
Name :......
Address of Institution/Government Hospital : ......
Qualification/designation of specialist :......
SEAL
Signature/Thumb impression* of the patient Note: *Strike out whichever is not applicable. ANNEXURE 7(II)
CERTIFICATE OF MENTAL RETARDATION FOR GOVERNMENT BENEFITS
This is to certify that Shri/Smt/Kum …………......
Son/Daughter of ………………….………………………………………...... of Village/Town/City ...... with particulars given below:-
(a) Age (b) Sex (c) Signature/Thumb impression
Categorisation of mental retardation Mild/Moderate/Severe/Profound Validity of the Certificate : Permanent
Signature of the Government Doctor/Hospital with seal Chairperson Mental Retardation Certificate Board
Recent Attested Photograph showing the disability affixed here.
Date :
Place : Annexure 7(III) STANDARD FORMAT OF THE CERTIFICATE
Name & Address of the Institute/Hospital issuing the certificate
Certificate No...... Date......
CERTIFICATE FOR THE PERSONS WITH DISABILITIES This is to certify that Shri/Smt/Kum...... son/wife/daughter of Shri...... Age...... old male/female, Registration No...... is a case of ...... He/She is physically disabled/visual disabled/speech & hearing disabled and has...... % (...... per cent) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her......
Note:- 1. This conditions is progressive/non-progressive/likely to improve/not likely to improve. 2. Re-assessment is not recommended/is recommended after a period of...... months/years.
*Strike out which is not applicable.
Sd/- Sd/ Sd/- (Doctor) (Doctor) (Doctor) Seal Seal Seal
Signature/Thumb impression of the patient.
Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)
Recent Attested Photograph showing the disability affixed here.