PROFORMA-cum-RE QUISITION

FOR SEEKING FINANCIAL ASSISTANCE

FOR MEDICAL TREATMENT/EXGRATIA UNDER
“CHIEF MINISTER’s RELIEF FUND” Latest Photo
To

The Hon’ble Chief Minister,

Govt. of Telangana
Hyderabad.

01. Name of the Patient/Beneficiary : RANI BHAI MAHENDRAKAR

(with Surname)

02. Mother’s/Husband’s Name : GANGARAM

03. Age : 71 YEARS

04. Permanent Address:

H.No. : 8-4-544/S/3
Street/Village : SULTHAN NAGAR, ERRAGADDA
Mandal : KHAIRTABAD
District : HYDERABAD
Pin Code : 500018
Phone No. (if any) : 9247167105

05. Address for Correspondence:

H.No. : 24-1398/D
Street/Village : LENIN NAGAR
Mandal : GAJULARAMARAM
District : MEDCHAL MALKAJGIRI
Pin Code : 500055
Phone No. (if any) : 9247167105

06. Name of the Disease/Purpose for seeking : __________________________

exgratia/financial assistance

07. Name & Address of Hospital with Phone : BASVATARAKAM INDO AMERICAN
CANCER HOSPITAL
& Fax Number 040-23542120

08. Date of Surgery/Operation : 22-07-2022

09. Estimated/Requested Amount (Hospital : 1,89,479.00

estimation in ORIGINAL to be enclosed)

10. Whether any amount was sanctioned under : Source __________Amount:Rs.

CMRF or from any other source

11. Ration Card/Income Certificate : YES

The above information given by me is true and correct as per my knowledge and I request you to
sanction financial assistance under CMRF.

Yours faithfully
Place:
Date:
SIGNATURE OF THE PATIENT

Enclosures:
1. Hospital Estimate in original
2. Copy of White Ration Card/Income certificate issued by the MRO.