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(Download) Format for Disability Certificate

(IN CASE OF AMPUTATION OR COMPLETE PERMANENT PARALYSIS OF LIMBS AND IN CASES OF BLINDNESS)

(See rule 4)

This is to certify that I have carefully examined Shri/Smt/Kum____________________Son/wife/daughter_________________________
Date of Birth________________ Age _______________years, male/Female___________
Registration No.___________________ permanent resident of Home No._____________________
Ward/Village/Street____________________Post Office_______________ District_____________
State____________________.

Whose photograph is affixed above, and an satisfied that :

(A) he/she is a case of:

locomotor disability
blindness

(Please tick as applicable)

(B) the diagnosis in his/her case _____________________________
(A) He/She has __________________________% (in figure)___________________ percent(in words) permanent physical impairment/blindness in relation to his/her__________________(part of body) as per guidelines(to be specified).