Certificate of the medical authority for certifying ‘person with disability‘, ‘severe disability‘, ‘autism‘, ‘cerebral palsy‘ and ‘multiple disability‘ for purposes of section 127 and section 154 of the Act.

Part –A

Basic Information

1

Details of taxpayer

(i)

Name

(refer Note 1)

(ii)

Address

(refer Note 2)

(iii)

Permanent Ac-

count Number

2

Tax Year

Part – B

To be filled by the Medical Authority

3

Certificate Number

4.

Date

dd/mm/yyyy

5

Details of the patient

(i)

Name

(refer Note 1)

(ii)

Son / Daughter/ Care of

(iii)

Age

(iv)

Gender

6

Registration No.

7

Disability type:

(select one)

1. Person with disability

2. Person with severe disability

8.

Suffering from:

(select one)

1. Autism

2. Cerebral palsy

3. Multiple disability

9.

Condition*:

(select one)

1. Progressive

2. Non-progressive

1. Likely to improve

2. Not likely to improve

10.

Reassessment:

(select one)

1. Recommended

After

Years

Months

2. Not recommended

11.

Details of of Institution/ Government Hospital:

(i)

Name:

(refer Note 1)

(ii)

Address:

(refer Note 2)

12.

Qualification / designation of specialist:

Signature / Thumb impression of the patient

Certified by

Signature of specialist