Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697805265481.pdf (India)
Application For Financial Assistance from Vice-President’s Discretionary Grants 1.

Name of the Patient 2.

Age/Sex of the Patient 3.

Father’s/Husbands Name 4.

Number of Family Members (Paste photograph of patient here) 5.

Residential correspondence copy of proof) address for (Enclose a Medical Natural Calamity Nature/Details of the calamity occurred: Injury Death 6.

Telephone/Mobile Number of the patient/applicant 7.

AADHAAR Card No.

(if (Please Enclose available) self attested copy of the card) 8.
Purpose for the grants: (Pl.

tick the relevant field) Provide Note: 1. disease/ailment/treatment Required, in case of Medical Purpose.

nature of Attach death 2. certificate/medical certificate, as applicable, in case of grants Calamity under purpose.

Natural 9.

Quantum Financial of Assistance required for the Medical treatment as per by estimate the given hospital (Enclose Expenditure Estimate from the Govt./Private Empanelled Hospital) 10.
Whether any assistance from Vice-President’s grant was received in the past by the patient?

other source 11.

Whether applied/eligible for of any funding/Assistance from any Govt.

agency/NGO/Insurance company/Hospital/Employer etc.?

If Yes, give details 12.

Whether patient or the person on whom he/she is dependent is an employee of Central Govt./State Govt./Local Bodies/PSU?

13.

Occupation and monthly income of the patient or the person on whom he/she is dependent.
(Attach Income Certificate issued by district revenue authority.)

14.

Any other relevant Information Date: (Name: Signature of the patient/Applicant ) (Mention name of the applicant alongwith relation with the patient, if application is not signed by patient)