CERTIFICATE OF MENTAL RETARDATION FOR GOVERNMENT BENEFITS

This is to certify that /Smt./Kum. ________________________________Son/Daughter of ______________________________of Town/City __________________________________________ with particulars given below:-

1. Age
2. Sex
3. Signature/Thumb impression

CATEGORISATION OF MENTAL RETARDATION
Mild/Moderate/Severe/Profound
Validity of the Certificate: Permanent

Signature of the Government
Doctor/Hospital with seal
Chairperson Mental Retardation
Certification Board


Recent Attested Photograph
Showing the disability affixed here

Dated:
Place:

STANDARD FORMAT OF THE CERTIFICATE

NAME & ADDRESS OF THE INSTITUTE / HOSPITAL ISSUING THE CERTIFICATE

Certificate No.
Date

CERTIFICATE FOR THE PERSONS WITH DISABILITIES

This is to certify that Shri/Smt./Kum/wife/daughter of Shri __________________________ Age ______________old male/female, Registration No. ______________________________ is a case of physically disabled/visual disabled/speech & hearing disabled and has ____________ % (____________________) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her ____________________________________________________

Note: -1. This condition is progressive/non-progressive/likely to improve/not likely to improve. *
2. Re-assessment is not recommended/is recommended after a period of ____________________ months/years.
*Strike out which is not applicable.
Sd/- Sd/- Sd/-(DOCTOR) (DOCTOR) (DOCTOR) Seal Seal Seal

Signature/Thumb impression
Of the patient

Countersigned by the
Medical Superintendent/CMO/Head of
Hospital (with seal)Recent Attested PhotographShowing the disability affixed here.