TEA BOARD

Application Form for Board’s Financial Assistance for Disabled Persons

Dependent on Tea Plantation Workers.

1, a) Name of the applicant(in block letter):

b) Monthly income of family :

c)Adhar card No. of Parent :

2. Name of the disabled person and his/her relationship with the

applicant………………………………………………………………………………

a) Name: b) Relationship: c) Age:

3.Name of the garden where the applicant is employed………………………………

4. Nature of disability…………………………………………………………………

5. Name of the articles required and cost of the article……………………………

(To be supported with a proforma invoice or a certificate regarding the price from

Supplier)

6. Name of the Bank details and contact No.

7. AADHAR NO IF ANY :

8.DECLARATION BY THE APPLICANT:

I hereby declare that the statements given in this application are true to the best of my

knowledge and belief and that the disabled persons mentioned herein has been residing

with me and wholly dependent on me.

(Signature or thumb impression (Signature or thumb impression of the applicant)

Of the disabled person

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9. CERTIFICATE OF THE MEDICAL OFFICER:

Certified that Shri/Smt.…………………………………………………. Wife/son/daughter of

Shri/Smt…………………………………………………….. employed in the

……………………………………………..Tea Estate is a disabled person and for his/her disability

he/she essentially requires(name of the articles) ……………………………….

…………………………………………………….The nature of the disability is...................................

Place: Signature and designation of

Date: Medical Officer and the Hospital/

Dispensary to which attached.

(Seal) Registration No.

10. RECOMMENDATION OF THE MANAGER OF TEA ESTATE:

…………………………………………………………… certified that Shri/Smt.

…………………………………………………………..is employed in this Tea Estate

since………………… All the entries made in this application have been duly verified by

me and found to be correct to the best of my Knowledge.

(Seal of the Te Estate) Signature of the Garden Manager

Regd. No. of Te Estate:

Date and Place:

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11.RECOMMENDATION OF THE REGIONAL/SUB REGIONAL OFFICE OF THE TEA BOARD.

(If the Tea Estate in which the applicant is employed is not member of any Tea

Producers’

Association)…………………………………………………………………………………

Verified and recommended payment of Rs……………………being the estimated cost of

The ……………………………………………………………………………………….

(Seal of the Office) Signature of Board’s Officer

Date and Place:

N.B. The Board will give grant to all those disabled persons and dependent of tea

garden workers who have purchased the required articles irrespective of submission of

prior application or not. Payment of 90% eligible amount in one go on submission of

application along with the relevant bills as a proof of procurement of articles duly

certified by the Consultant Medical Officer, Manager/authorized signatories of Tea

Estates of the Regional/Sub-Regional Office of the Tea Board.

Tea Board

APPLICATION FOR LUMP- SUM GRANT ON “ NEHRU AWARD”

1. Name of the student(in capital letters): 2. Name of the state to which the student belongs: 3. Name and address of the institution from

Where are applicant passed the last Madhyamik/

Secondary/ Higher Secondary Examination :

4. Class/Course studying : (a) Percentage of marks obtained in the last

Madhyamik/ Secondary/Higher Secondary or equivalent

Examination (Attach a copy of the relevant

Mark-sheet duly attested by a Gazetted Officer):

(b) Name of the tea garden through which the Application is forwarded

5. Details of future studies : 6. Name of the guardian : 7. Name of the employer of guardian with address : 8. Annual Income of Parents : 9. Bank details and contact No

.

10. Aadhar card No. If any :

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(Signature of the Applicant)

I hereby declare that the particulars furnished in the above application are true to the best

of my knowledge and belief.

Date : …………………………………………..

Place : (Signature of guardian )

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11. RECOMMENDATION OF THE MANAGER OF TEA ESTATE:

…………………………………………………………… certified that Shri/Smt.

…………………………………………………………..is employed in this Tea Estate

since………………… All the entries made in this application have been duly verified by

me and found to be correct to the best of my Knowledge.

(Seal of the Te Estate) Signature of the Garden Manager

Regd. No. of Te Estate: Date and Place:

TEA BOARD

SPECIAL SCHEME FOR SPECIAL CASES OF MEDICAL TREATMENT FOR CANCER

& HEART PATIENTS

Application for claiming refund of medical expenses incurred in connection with medical attendance

and /or treatment Tea garden workers and their dependents.

N.B. Separate form should be used for each patient.

1. Name of the applicant(in block letter) : 2. Name of the Tea Co/ Tea Estate : 3. Name of the designation of the applicant : 4. Monthly income limit : 5. Name of patient/dependent : 6. Name of the Hospital/clinic where treated with address: 7. Duration of the treatment : 8. Total Cost of the treatment 9. Aadhar No. if any :

i) DETAILS OF THE AMOUNT CLAIMED FOR OUT DOOR TREATMENT DULY

CERTIFIED BY THE DOCTOR//AUTHORITY OF TEA COMPANY/TEA ESTATE.

(A) Name of the Doctor/Specialist with Registration No. (B) Fees for medical consultation : (C) No. of consultations : (D) Number and dates of injections and the fees paid : (E) Name of Laboratory/clinic and Charges for pathological /radiological test : (F) Cost of medicines etc. : (G) Charges for therapy etc.

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ii) DETAILS OF INDOOR TREATMENT CERTIFIED BY THE DOCTOR/

AUTHORITY OF TEA COMPANY/TEA ESTATE.

I) Accommodation charges :

II) Diet charges : III) Charges for Surgical operation or medical treatment : IV) Pathological and Radiological charges : V) Cost of Medicines etc. VI) Charges for Special Medicines etc:/Oxygen : VII) Ambulance charges : VIII) Any other charges essential for the treatment : IX) Bank details and contact No. :

Total Amount claimed

List of enclosures :

DECLARATION TO BE SIGNED BY THE EMPLOYEE OF TEA CO./TEA.ESTATE.

A) I hereby declare that statement in this application is true to the best of my knowledge and belief and that the person for whom medical expenses were incurred is whole dependent upon me.

B) I hereby declare that my father/mother/son/daughter/sister/Shri/Smt …………………….. …………………………………………………was residing with me during the period of his/her

sickness for which the medical expenses reimbursement claim is submitted along with

all original money receipts/cash memo duly certified . The income of my father/

mother/son/ daughter/dependent was Rs………………. which is within the ceiling limit.

Date: ………………………….. Signature…………………………..............

CERFTIFIED BY DOCTOR/AUTHROSED OFFICER

IN TEA COMPANY/TEA ESTATE WITH DATE AND SEAL.

10.RECOMMENDATION OF THE MANAGER OF TEA ESTATE:

……………………………………………………………Certified that Shri/Smt.

………………………………………………………….is employed in this Tea Estate

Since………………………….. All the entries made in this application have been duly

verified by me and found to be correct to the best of my knowledge.

(Seal of Tea Estate) Signature of the Garden Manager

Regd. No. of the Tea Estate: Date and Place:

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11.RECOMMENDATION OF THE REGIONAL/SUB REGIONAL OFFICE OF THE TEA

BOARD.

(If the Tea Estate in which the applicant is employed is not member of any Tea Producers’

Association)…………………………………………………………………………………..

Verified and recommended payment of Rs……………….. being the estimated cost of the

……………………………………………………………………………………………..

(Seal of the Office) Signature of Board’s Officer

Date and Place:

Tea Board

APPLICATION FOR BOOK AND SCHOOL UNIFORM GRANT

1.Name of the student(in capital letters): 2.Name of the state to which the student belongs: 3.Name and address of the institution from Where are applicant passed the class VIII/XII. :

4.Class/Course studying : (a)Percentage of marks obtained in the Class VIII and

Higher Secondary

(Attach a copy of the relevant

Mark-sheet duly attested by a Gazetted Officer):

(b)Name of the tea garden through which the Application is forwarded :

5. Details of future studies : 6.Name of the guardian : 7.Name of the employer of guardian with address : 8.Annual Income of Parents :

9. Bank Details and contact No. :

10. Aadhar No, if any :

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(Signature of the Applicant)

I hereby declare that the particulars furnished in the above application are true to the best

of my knowledge and belief

Date :

Place : (Signature of guardian )

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11.RECOMMENDATION OF THE MANAGER OF TEA ESTATE:

……………………………………………………………Certified that Shri/Smt.

………………………………………………………….is employed in this Tea Estate

Since………………………….. All the entries made in this application have been duly

verified by me and found to be correct to the best of my knowledge.

(Seal of Tea Estate) Signature of the Garden Manager

Regd. No. of the Tea Estate:

Date and Place:

TEA BOARD

Application Form of Medical Treatment Facilities and Purchase of Medical Equipments,

Accessories and Ambulance

1. Name of the Hospital with the full address

( in block letters)

2. Year of Establishment:

3. Registered by

(a) Nature and types of treatment facilities

Existing in the Hospitals with details

Of wards and beds available.

(b) No. of free and paid bed in each ward:

4. (a) Details of Hospital personnel/staff

(b) Equipment and Laboratory

(i)No. of X-Ray Unit :

(ii) Pathological test facilities:

(iii) Operation Theatre:

5. No. of patients treated from tea estates with

Details for the last three years:

6. Applicant shall submit the Rules and by-laws of

The Institution:

7. Income & Expenditure statements for the last

3 years.

8. a) Names of tea estates within a radius of 50 KM Name of T.E. In kms.

From the Hospital/clinic with actual

Distance of each tea estates from the Hospital/ Clinic

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b) Names of similar institutions in near by area of

tea plantation with address and distance from

the site of proposed project:

c) Names and address of the existing Hospitals/

Group Hospitals attached to tea estates in the

Neighbourhood.

Whether any capital grant was released from

Tea Board previously and, if so, please mention

The details thereof.

10. Details of the purpose for which the capital grant

Is sought for from Tea Board.

11.Total estimated cost of the project (detailed plan

And estimate in duplicate prepared and signed by

An approved technical authority and countersigned

By the Head of the Institution should be attached)

12. Source of Funds for the project (documentary

Evidence of commitment will be preferable

Reserve fund of the Hospital, if any

i) special grant from the Government

ii) Special subscriptions/Donations

iii) Grant sought for from Tea Board

v) Any other source :

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Total: …………………………………..............

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13. In the event of the Tea Board sanctioning the grant

The period within which the project can be completed

14. Details of the existing structure and vacant land, if

Any

(a)Whether the institution has land for the project,

and, if so, its area accompanied by site plan in

duplicate is to be furnished.

b) The terms on which the land is held is to be stated

and this should be supported by an attested copy

of the documents including that the Hospital has

a clear and marketable title to the properly and

the same is free from encumbrances and

attachments.

15.Concessions to be provided for tea plantation workers

And their dependents in lieu of the capital grant sought

For from Tea Board.

i)No. of beds to be reserved in the Hospital for tea

plantation workers and their dependents

ii)Period of reservation

iii) No. of free beds including free treatment and diet

to be provided for patients from tea estates.

iv) No. of reserved beds to be provided for patients

from tea estates at concessional rates with

indication of charges under bed rent, cost of

treatment, operation, diet charges etc.

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16. a) Ordinarily, when the Board agrees to make a grant,

25% of the grant will be released on declaration

With supporting documents to be given by the

Grantee institution to the effect that it has spent its

Own share of the project cost and that the progress

Of the project is proportionate to the expenditure

Made by grantee institute. 65% will be released on

Of the audited statement of expenditure of

Grantee institution’s own share and of Board’s grant.

10% will be released on submission of the completion

Certificate and audited accounts of expenditure for

The entire project. The interval between the drawl

Of the first instalment and the second instalment

Should not be more than six months and between

The second and the final instalment not more than

12 months. In the event of delay, the Board will

Retain the right to have the instalments refunded

By the grantee institution.

Will this basis be acceptable to institution ? Yes/No.

b)In respect of grant for purchase of medical equipment,

accessories, ambulance etc. grant amount in the form

of RTGS/CHEQUE to be drawn in the name of suppliers

may be sent to grantee intuition for taking delivery

of required medical equipment, accessories, ambulance

etc. from the supplier towards completion of the

project within Six months from the date of receipt

of amount. In the event of delay, Board will retain the

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right to have the grant amount refunded by the

grantee institution.

17. Will this basis be acceptable to institution? Yes/No.

Any reduction in the original estimate of expenditure

By more than 5% has be reported to the Board and in

Such an event, the Board shall retain the right to

Adjust the grant.

Will this basis be acceptable to institution? Yes/No

18.Under the capital grant rules, a representative of

The Tea Board is to be nominated on the

Managing Committee/ the Governing Body of the grantee

Institution. Is this possible under the existing Rules

Of your institution or prior permission of the

State Govt. for such nomination will be necessary? Yes/No.

19.In the event of a grant whether the institution is

Agreeable to execute an agreement with the Tea Board

On Stamp papers at the cost of the Institution of

Appropriate value embodying the terms and

Conditions. Is there any need for the Hospital

To seek approval of the State Government to accept such of

The terms and conditions of the grant as may

Affect the Management of the Hospital in

Any way before embodying them an Agreement? Yes/No.

Place: Signature…………………………………..

Date: (Head of the Institution)

Name…………………………………………

( Office Seal )

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N.B. All columns of the application Form should be read carefully and filled in by the Applicant. The

application, complete in all respects including the Annexure required, should be sent to the

Executive Director, Coonoor/Guwahati as per their jurisdiction.

Tea Board

APPLICATION FOR EDUCATIONAL STIPEND (FORM No. I)

No. OEIGINAL

All columns in the form should be filled in. All

Applications should be submitted within one year

From the date of commencement of an academic

Year/session. Incomplete application forms or

Applications submitted after prescribed date will

Not be taken up for consideration.

1. Full name of the student…………………………………………………………………….

(in CAPITAL LETTERS)

2. A) Date of birth……………………………………………b)Nationality……………………

C)Sex………………………………………………. D) If the student belongs to a Scheduled

caste/Tribe, say ‘’Yes’’ or ‘’No’’ and , if yes, mention Scheduled caste or Scheduled Tribe……..,..

3. Full Address (Present and Permanent)…………………………………………………………

………………………………………………………………………………………………….

4.Particulars of parents:

a) Name of father............................................................... b) Designation.....................................

c) His Address.................................................................................. d) Age....................................

e)Name and address of Tea Estate in which employed...................................................................

f)Name of mother................................................................g) Designation....................................

h) Her present address............................................................................. i) Age................... ..........

j) Name and address of Tea Estate in which employed....................................................................

......................................................................................................................... ..............................

k) Adhar card No. of parent/guardian.............................................................................................

5.Monthly total income of the parents..................................................................................................

To be filled in by Tea Board Office. Index No. Regd. No. If sanctioned

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6.In case both the parents are not alive, please give particulars of guardian:

a) Name in full...............................................................................b) Designation.................................

c)Present address.................................................................................................................................

d)Name and address of Tea Estate in which employed.......................................................................

e) Monthly total income...................................................................................................... ..................

f)His/her exact relationship with the student..........................................................................................

g)If any other dependent of guardian is in receipt of the Tea Board stipend, particulars thereof...........

..................................................................................................................................................................

7.a) Name and address of the institution where admission has been secured for the current

academic year...........................................................................................................................................

b)Class, Sec. & Roll No...................................................................................................... .......................

c) Affiliated to/recognized by...................................................................................................................

d)Name and nature of the course (part time/full time) and its duration.................................................

e)Duration of the current academic year/session:

From............................................................ to........................................................ ............................

Date Month Year Date Month Year

f) Whether residing in an affiliated hostel and, if so, address thereof...................................................

................................................................................................................................................. .................

g) Months during the academic year when the hostel remains closed....................................................

8.Name of the last annual/public examination passed mentioning the year of passing the

examination (attach attested copy of Mark sheet)..................................................................................

9.a) Whether the student is in receipt of any other scholarship or financial assistance from the State

Government/University or any other institution or person during the academic year? (say ‘yes’ or

‘No’ and, if yes, give full particulars including the monthly rate, date of award etc............................

............................................................................................................................. .....................................

b)whether brother(s)/Sister(s) of the students is/was in receipt of stipend from Tea Board (say ‘Yes’

or ‘No’ and, if yeas write in details..........................................................................................................

10.Nature and amount of Tea Board stipend applied for :

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i)Tuition fee (including all other fees) payable not more than Rs.20,000/-............................................

for the academic year/session.

ii)Hostel charges.

a)Set rent per session (not more than Rs.20,000/-……………………………………………

b)Establishment Rs………………………………………………

c) Fooding charges Rs.…………………………………………………. 11. Bank Details: …………………………….. 12. Aadhar No, if any…………………

13. DECLARATION BY THE STUDENT AND THEIR PARENT/GUARDIAN:

We hereby declare that the statement made by us in this application form are true to the best

of our knowledge and belief. We also confirm that the applicant student was not detained in

the same class (in last year or in any year) for which class the stipend is applied for. We further agree to abide by the terms and conditions of the award, if the application is selected

for the grant of stipend applied for:

Signature of the student with Signature of the father/mother/guardian

Date and place (who is working in Tea Estate) with

Date and place.

Enclo: List of documents to be attached as per item No. 8.

14.RECOMMENDATION OF THE HEAD OF THE INSTITUTION

Certified that I have verified the statements given in this application except items 4(f),5,6(e)

to (g) & 9(b) from the records and found them to be correct to the best of my knowledge and belief. The student is regular in attendance and his conduct is good. He/.she is not in receipt

of any other stipend or help during the session and has/have not applied for any other

concession of tuition fees for the class in which he/she is reading or from the community to

which he/she belongs. The applicant resides in a hostel affiliated to this institution. The institution receives/does not receive grant-in-aid from the State Government.

(Seal of the institution) ( )

Signature with name of the Head of the institution

Date & Place……………………………………..

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15.RECOMMENDATION OF THE MAMAGER OF TEA ESTATE

Certified that both the parents/father/mother/guardian of Shri/Kum…………………………

……………………………………………………..is/are employed in this Tea Estate since……………………………… and all the entries made in this application have been

verified by me. The ward for whom the stipend is applied for is a member of the ‘family’

Of the employee(s) as defined in the Plantation Labour Act.

(Seal of the Tea Estate) ( )

Signature with name of the Manager, Tea Estate

Registration No. of Tea Estate………………….

Date & Place…………………………………….

RECOMMENDATION BY TEA PRODUCERS’ ASSOCIATION (IF THE PARENT/GUARDIAN OF THE STUDENT IS A WORKERS OF THE TEA ESTATE

DRAWING TOTAL CASH EMOLUMENTS NOT MORE THAN RS.25,000/- PER

MONTH)

Certified that the parent/guardian of the student is employed in…………………………..

…………………………………………..Tea Estate of M/s…………………………………..

……………………………………………and is in receipt of total emoluments RS…………..

(including D.A. Non-practicing allowance etc.) per month.

(Seal of the Association) ( )

Signature with the name of the Secretary of

The Association.

Date & Place………………………………………