Ministry of Social Justice and Empowerment (MSJE)

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Personal
Details

Attachments
Details

Proposed Guardian’s
Details

Applicant
Details

Personal Details

Personal Details of Person with Disability

Name of Person with Disability (PwD) *:

Date of Birth *:

Age :

Gender *: Male Female

Marital Status *: Single Married

Father's Name *:

Mother's Name * :

Address * :

State * :

District * :

Pincode *:

PWD Aadhaar Card No.*:

PWD DOCUMENT DETAILS

Attach Proof of Residence of PWD* :

Select Disability Type* :

Disability Name	Percentage
	%

Issuing Authority of Disability Certificate * : The Disability Certificate should be from any recognized Government Hospital.

Issuing authority Name	Designation	Address	Contact Number

Attach Disability Certificate* :

PERSON WITH DISABILITY ASSETS DETAILS

PwD does not have Movable Property (Select this option in case of No movable property) Details of Movable property on which PwD has share * :

Attach proof * :

Details of Immovable property on which the PwD has share as per format *: PwD does not have Immovable Property (Select this option in case of No Immovable property)

Survey No.	Village/Town	Measurement of the immovable property	Other Information

Proposed Guardian’s Detail

Proposed Guardian * Individual or Both Guardian Organisation

In case the proposed guardian is a parent, then the name of the other parent must also be included.

Individual or Both Guardian’s Detail

Guardian’s Name * :

Name of other parent:

Address * :

State * :

District- * :

Pin code * :

UDID No :

AadhaaR Card No. :

Relationship of PwD with Proposed Guardian * : Parent Relative Registered Organization Any Other

Parent/NGO Email ID * :

Contact Details * :

If Any Other Email (NGO), please specify :

Combined photo of proposed guardians with PwD ( jpg,png ) * :

Consent of the person proposed to be appointed Guardian. * : Yes No

Attach proof of consent * :

Consent of the existing Guardian, if any * : Yes No

Attach proof of residence of proposed Guardian. * :

Undertaking by the applicant that the proposed Guardian is:* :

A citizen of india

Is not of unsound mind or is currently undergoing treatment for mental illness.

Does not have a history of criminal conviction.

Is not a destitute and dependent on others for his own living (proof of income source to be attached)

Has not been declared insolvent or bankrupt.

Note: Before submission please make sure about below points:
(i) PDF file should be less than 5MB
(ii) JPG/PNG file should be less than 35KB
(iii) Don't use same file name for two or more files.

Organization Guardian’s Detail

Organization Name * :

NT Registration No. *:

Date of Reg. *:

Registration Number under PwD Act,1995 * :

Validity*: From To Lifetime

Address * :

State * :

District * :

Pin code * :

Name of the Head of Organisation * :

Designation * :

Other than Head of Organisation then please specify name of the person :

Email ID * :

Contact Details * :

Consent of the person proposed to be appointed Guardian. * :

Combined photo of proposed guardians with PwD ( jpg,png ) * :

Attach proof of consent * :

Consent of the existing Guardian, if any * :

Attach proof of consent (Click here to print consent form, then fill it up, get signature and attach the scanned copy) * :

Undertaking by the applicant that the proposed institution is* :

Recognised by State/Central Govt.

Has 2 years of experience in offering disability rehabilitation services including running residential facilities or hostel to the respective category of persons with disability.

The residential facility shall maintain minimum standards in terms of space, staff, furniture, rehabilitation and medical facilities as specified by the Board.

Note: Before submission please make sure about below points:
(i) PDF file should be less than 5MB
(ii) JPG/PNG file should be less than 35KB
(iii) Don't use same file name for two or more files.

Applicant Details

Name of Applicant * :

Address* :

State * :

District * :

Pincode* :

UDID No.:

Aadhaar Card No.:

Relationship of PwD with Applicant.* : Parent Relative(relative means related by blood,adoption,marriage) Registered Organization Any Other

Tick the obligations for which Guardianship is to be given* :

Maintenance and Residential Care Management of immovable property Management of movable property Any other?

First Witness Name* :

Address* :

Contact No* :

Aadhaar Card No.:

Second Witness Name* :

Address* :

Contact No.* :

UID No :

Aadhaar Card No.:

Guardianship Application is normally required to be filed jointly by either both the Parents or all the siblings as the case may be. Please confirm whether this application is joint or not.* : Single Application Joint Application

I/We confirm that all the facts given above by me/us are true and correct to the best of my/ our knowledge and as stipulated under the National Trust Act and its Rules and Regulations

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Please fill all * Marked mandatory fields