De-4 Form - Directorate Of Estates Form Page 2
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1
29.
In case, Change is requested on Medical Grounds, please fill-up the following:
On Medical Grounds of
In case of Dependent
Self
Dependent
Name of Dependent
a)
Relation with Applicant
Whether the Certificate showing the relationship between Applicant and Patient attached
YES
NO
Disease
Whether Original copy of the Medical Certificate is attached ?
YES
NO
Whether Photo and Signature of Patient and token number of CGHS Card of the applicant
YES
NO
b)
are on the Certificate ?
In case of T.B., whether X-RAY is attached ?
YES
NO
In case of Physically Handicapped, whether Full Photograph showing Disability /
YES
NO
Deformity is affixed on the Certificate ?
Have you applied earlier for ad-hoc allotment on medical grounds ?
YES
NO
If YES,
c)
then give
full details
Have you been allotted Government accommodation on medical grounds earlier?
YES
NO
If YES,
d)
then give
full details
Whether specific recommendation from Head of the Department / Joint Secretary
e)
YES
NO
(Administration) / Secretary to Government of India is enclosed ?
DECLARATION
(a) I have not availed change of residence earlier in the type of accommodation presently occupied by me.
(b) This is the first application for such a change.
(c) This application is in modification of the preferences given by me vide Serial No. _______________ of the
Waiting list for the month of _____________________________________20______.
Date: ______________________
Signature of the Applicant : _____________________________
_
TO BE FILLED IN BY THE FORWARDING OFFICE
Department Code
Endorsement No.
Date
Office Name
Forwarded to the Directorate of Estates, New Delhi-110011. The facts stated above are correct.
Signature with Date : _______________________________
Name
____________________________________
Office Seal
Designation
____________________________________
Phone
____________________________________
E-mail
____________________________________
Please contact Information Facilitation Centre at Nirman Bhawan (Ground Floor, Near Gate No.2)
for any allotment related information on any working day between 10.30 AM to 4.30 P.M.
E-mail :
estate@nb.nic.in
Web-site:
Phone No. : 3022199 Ext. 2890
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