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67 Female SC JAMUNA DEVI RAM SWAROOP 52 GULADIYA

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67 Female SC JAMUNA DEVI RAM SWAROOP 52 GULADIYA भररत सरकरर सरमरजजक नयरय एवअ अधधकरररतर मअतरलय ररषषषय वययशश ययजनर RASHTRIYA VAYOSHRI YOJANA भररतशय कक ततम अअग ननमररण ननगम (भररत सरकरर कर एक 'ममनशरतन' सरवजननकर उपकम) जश. टष. रयड, करनपरप - २०८०९६ आई एस ओ ९००१:२००० पनतषषरन ARTIFICIAL LIMBS MANUFACTURING CORPORATION OF INDIA (A GOVERNMENT OF INDIA 'MINIRATNA' UNDERTAKING) G.T. ROAD, KANPUR-208016 AN ISO 9001:2000 COMPANY Camp Venue : NAGAR PANCHAYAT ,MAJHOLA Slip No. : 2017-18/PBRV10/T7/00621 Assessment Date : 30/05/17 PART I लरभररर कर नरम :JAMUNA DEVI आयप : 67 मलगअ : Female Name of the Beneficiary Age Sex पपतर/पनत कर नरम :RAM SWAROOP जरनत : SC Father's/Husband's Name Category पतर :52 GULADIYA BHINDARA MAJHOLA मयबरइल नअ. : Address PILIBHIT Mobile No. :PILIBHIT शहर/क़सबर/गरअव पपनकयड : 262001 City/Town/Village Pin Code बश. पश. एल. करड र न. : B.P.L. Card No. ररजय :UTTAR PRADESH जजलर : PILIBHIT State District वदधरवसररक पपशन न. आधरर करड र नअ. : Aadhar Card No. : Aadhar Card (3xxxxxxxxxx3) Old Age Pension No. PART II Type of Disability : 1. LOCO MOTOR (40%) 2. LOW VISION (40%) 3. LOSS OF TEETH (40%) S.No. Appliances Detail Remark Quantity Value 1 TD OT 17 Spectacles 1 800.00 2 TD 1N 61. Walking Stick (Cane) 1 420.00 3 PU 0B 38 Artificial Dentures Rigid-Partial Set 2 2000.00 Total 4 3220.00 पनवररसप पवशशषज / धचककतसरधधकररष कश हसतरकर एवअ मयहर Signature of Rehab. Professional/Medical Officer & Stamp PART III म म JAMUNA DEVI पमरणणत करतर/करतश हगह कक मनम श पपछलश तशन वषर मप भररत सरकरर/ररजय सरकरर यर अनय समरजजक ययजनर कश अअतगतर ककसश शरसककय/अशरसककय/अनय सअसरर सश कयई उपकरण परपत नहषअ ककयर हह। यदद मशरश दवररर दष गई सचनरएहग गलत परई जरतश हह तय मझशप आपनतग र ककयश गयश उपसकर एवअ उपकरण कक परषग लरगत भगतरनप कश सरर मशरश ऊपर करननशग कररवरहष ककयश जरनश कश मलए भश सवयअ जजममशदरर हयऊअ गर। I JAMUNA DEVI certify that I have not received similar Aid/Equipment either free of cost/subsidised in the last three years* from any Government/Non Government organization. In case the undertaking is found false, I will be liable for legal action beside recovery of the full cost of aids and appliances supplied, from me. पनवररसप पवशशषज / धचककतसरधधकररष कश हसतरकर एवअ मयहर वररषष नरगररक लरभररर कश हसतरकर / अअगषरग ननशरनश Signature of Rehab. Professional/Medical Officer & Stamp Signature/Thumb Impression of the Senior Citizen Beneficiary उपकरण परवतश RECEIPT OF APPLIANCES PART IV म म JAMUNA DEVI पमरणणत करतर/करतश हगह कक आज ददनरअक .................. मनम श भररत सरकरर कश RVY ययजनर कश अअतगतर 1. TD OT 17, 2. TD 1N 61., 3. PU 0B 38 उपकरण नननशलकप /ररयरयतश दर पर अचछच हरलत मप परपत ककयर हह। I JAMUNA DEVI certify that today ............... ,I received 1. TD OT 17, 2. TD 1N 61., 3. PU 0B 38 appliances under RVY scheme of Govt. of India at subsidized/free of cost of Rs. Nil & in a good working condition. प पनवररस पवशशषज / धचककतसरधधकररष कश हसतरकर एवअ मयहर वररषष नरगररक लरभररर कश हसतरकर / अअगषरग ननशरनश Signature of Rehab. Professional/Medical Officer & Stamp Signature/Thumb Impression of the Senior Citizen Beneficiary ASSESSMENT ACKNOWLEDGEMENT SLIP Camp Venue : NAGAR PANCHAYAT ,MAJHOLA परषकण परवतश पचर Slip No. : 2017-18/PBRV10/T7/00621 Date : 30/05/17 Delivery Date : 23/01/18 12:00 Name of the Beneficiary : JAMUNA DEVI Age : 67 Sex : Female Mobile No. : Type of Disability : 1. LOCO MOTOR (40%) 2. LOW VISION (40%) 3. LOSS OF TEETH (40%) S.No. Appliances Detail Remark Quantity Value 1 TD OT 17 Spectacles 1 800.00 2 TD 1N 61. Walking Stick (Cane) 1 420.00 3 PU 0B 38 Artificial Dentures Rigid-Partial Set 2 2000.00 Total 4 3220.00 पनवररसप पवशशषज / धचककतसरधधकररष कश हसतरकर एवअ मयहर Signature of Rehab. Professional/Medical Officer & Stamp.
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