<p> ANNEXURE 7 (I)</p><p>FORM NO. 10-IA [See Sub-rule (2) of rule 11A]</p><p>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</p><p>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*.</p><p>Sd/- (Neurologist/Pediatric Neurologist/Civil Surgeon/Chief Medical Officer*)</p><p>Name :...... </p><p>Address of Institution/Government Hospital : ...... </p><p>Qualification/designation of specialist :...... </p><p>SEAL</p><p>Signature/Thumb impression* of the patient Note: *Strike out whichever is not applicable. ANNEXURE 7(II)</p><p>CERTIFICATE OF MENTAL RETARDATION FOR GOVERNMENT BENEFITS</p><p>This is to certify that Shri/Smt/Kum …………...... </p><p>Son/Daughter of ………………….………………………………………...... of Village/Town/City ...... with particulars given below:-</p><p>(a) Age (b) Sex (c) Signature/Thumb impression</p><p>Categorisation of mental retardation Mild/Moderate/Severe/Profound Validity of the Certificate : Permanent</p><p>Signature of the Government Doctor/Hospital with seal Chairperson Mental Retardation Certificate Board</p><p>Recent Attested Photograph showing the disability affixed here.</p><p>Date :</p><p>Place : Annexure 7(III) STANDARD FORMAT OF THE CERTIFICATE</p><p>Name & Address of the Institute/Hospital issuing the certificate</p><p>Certificate No...... Date...... </p><p>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...... </p><p>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.</p><p>*Strike out which is not applicable.</p><p>Sd/- Sd/ Sd/- (Doctor) (Doctor) (Doctor) Seal Seal Seal</p><p>Signature/Thumb impression of the patient.</p><p>Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)</p><p>Recent Attested Photograph showing the disability affixed here.</p>