FORMS
Form scheme no. 2
HEALTH
ANNEXURE ‘A’
DOCTOR’s CERTIFICATE
This is to certify that Shri/Smt. __________________________________ husband/wife
of _________________________________ whose signature/LTI is appended below
has undergone sterilization operation successfully on _______________ at
________________________ ________________________ (Name of the Medical
Institution). I recommended that monetary compensation of Rs.200/- may please be
paid to him/her from the Beedi Iron Ore Manganese Ore and Chrome Ore, Limestone
and Dolomite Mine and Cine Workers Welfare Funds of the Labour Welfare
Organisation.
Signature ____________________
Signature/LTI
(Seal)
Shri/Smt. ____________________
Name of the Doctor _____________
ANNEXURE „B‟
Application Form for payment of Monetary Compensation for Sterilization.
1. Name of the applicant: Shri/Smt. _________________________________
2. Wife/Husband of : Shri/Smt. _________________________________
3. Identity Card No. _____________________________________________
4. No. of living children of the applicant.
5. Date of sterilization.
6. Name of Medical Institution where sterilization operation was conducted.
(i) It is requested that Monetary Compensation @ Rs.200/- may be sanctioned to me for
having undergone sterilization operation at
__________________________________________________.
(ii) A certificate issued by the aforesaid medical institution is enclosed herewith.
(iii) I undertake that I shall refund the said compensation if at any stage it is proved that it
is false claim.
_____________________________
Signature/Thumb impression of the
Applicant/Iron Ore, Limestone and
Dolomite/ Cine Workers.
Date: ___________________
Countersigned by Employer.
Scheme no. 3
ANNEXURE-I
APPLICATION FORM FOR THE PAYMENT OF LUMP SUM GRANTS OF Rs.1000/- TO
FEMALE WORKERS UNDER THE MATERNITY BENEFIT SCHEME FOR FEMALE BEEDI,
IMC, LSDM AND CINE WORKERS.
1. Name of the applicant :
2. Address :
3. Wife/Daughter of :
4. Identify Card No. :
5. Date of delivery :
It is requested that the lump sum grant of Rs.1000/- may kindly be sanctioned to me. Following
certificates are enclosed:i)Birth Certificate of the Child born.
ii) Certificate to the effect that I am a beedi, IMC, LSDM and Cine Worker.
The certificate shows that I have been a beedi, IMC, LSDM and Cine Worker for
at least six months before the delivery.
iii) Certificate to the effect that the benefit is being claimed for the first/second time.
I understand that I shall refund the said amount if it is proved that it is a false claim.
Dated: __________________
Signature/Thumb impression of the Applicant
Recommendation of the Medical Officer Incharge of the nearest dispensary of the Labour Welfare
Organisation.
Medical Officer Incharge
ANNEXURE-II
This is to certify that Smt. __________________________________________
wife/daughter of Shri _________________________________________________
is a beedi/IMC/LSDM/Cine Worker. She is employed with
______________________ as on date and has been engaged in beedi
making/working as IMC/LSDM/Cine Workers for the last ________________
year(s) and ____________________ month(s).
** According to her statement which is enclosed. Her employer as per her
statement has refused to issue her the employment certificate. Her Identity Card
No. is ___________________________.
______________________________
Signature of Employer/Gazette Officer of
the Labour Welfare Fund
Organisation/medical Officer Incharge
of the nearest dispensary of the Labour
Welfare Organisation.
Dated _____________________
** This may be deleted in case the employer signs the certificate.
Scheme no.4
Annexure-I
FORM „A‟
Application form for financial assistance for Heart surgery or allied treatment.
To
The Welfare Commissioner,
Labour Welfare Organisation,
----------------------------------Sir,
I hereby apply for financial assistance for undergoing Heart Surgery or allied treatment in
___________ mention the name of the hospital where the Medical Officer, Labour Welfare
Organisation, has recommended the treatment. In this connection, I submit my particulars as under:1. Name of the Applicant in Full:
(In Block Letters)
2. Name and address in full of the
Mine/Beedi establishment/Beedi
Contractor/Agent
3. The date of his/her employment
and total continuous service.
4. Designation or the nature of
His/Her Employment.
5. His/Her monthly salary/wages
(Excluding bonus)
6. (a) Identity Card No. in case
ofBeedi/Cine Workers.
(b) „B‟ Register No. in case of
Mine Worker.
Signature of
Mine/Beedi/Cine worker
Name:
Place:
Date:
Certificate by the Mine Manager/owner and in case of beedi worker by owner of
Establishment/Contractor/Agent.
It is certified that Shri/Smt/Kum ______________________________________ is employed in this
mine/Beedi Establishment by me as ______________________ continuously with effect from
__________________________________ and information furnished by him/her as above are
correct.
Signature:
Designation:
Name & Address of the Mine/Beedi
Management/Contractor.
Date:
Seal of the Mine/Beedi Establishment
COUNTERSIGNED BY THE owner/Manager of the Beedi Establishment if the worker is working
under Contractor/Agent.
Date: OWNER/MANAGER
Name:
Designation:
Address:
CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO.
Certified that I have carefully examined Shri /Smt/ Kumari ________________________
__________________ and found him/her suffering from _____________________ disease. In my
opinion, his/her admission in the ________________ hospital which is recognized by the Govt. of
________________________ is absolutely necessary for Kidney Transplantation or allied treatment.
His/Her Identity Card No. is ______________________________/ „B‟ Register No. is
_____________________________________
Signature:
Name:
Designation:
Name of the Dispensary/Hospital
Dated:
FORM „B‟
Application for grant of subsistence allowance from the Labour Welfare Organisation under
the Scheme for Financial Assistance to Mine/Beedi/Cine workers suffering from heart diseases.
To
The Welfare Commissioner,
Labour Welfare Organisation.
Sir,
I hereby apply for financial benefits under the scheme for “financial assistance to mine/beedi
and cine workers for ___________ I have undergone treatment for ________________ in
_________________________ (mention the name of the hospital where the treatment has been
taken). I furnish my particulars as under: 1. Name of the applicant in full:
2. Date of birth/Age:
3. Full postal/residential address
of the applicant
4. Full address of the hospital
where the applicant has undergone
treatment
5. The reference No. and date of the
letter from Welfare Commissioner
permitting Him/her to undergo
treatment in the above hospital.
6. Amount actually incurred by the
applicant for treatment
(Furnish the details with supporting
billsetc, each bill has to be countersigned
by the hospital authorities with seal
and full signature)
a. Hospital charges including diet etc. Rs.
b. Expenses for pre post operation
Check ups: Rs.
c. Charges for heat valve etc, which were required to be purchased from
hospital/market (prescription slips to be enclosed)
Total :Rs.
7. Amount claimed as bus/No. of Mode of travel. Amount
Train charges
Persons
a) Date of outward journey
b) Date of inward journey
I hereby declare that the particulars furnished above are correct. If any of the particulars are
found to be incorrect. I realize that I will be liable for suitable action apart from refund of financial
assistance, if any received by me.
Signature of the Mine/Beedi worker
Place :
Date :
Certificate by the Management
It is certified that Shri/Smt/Kum. ______________________________ is employed in this
Mine/Beedi Establishment by me as ___________________ (mention designation) and that his/her
wage is __________________________ p.m.
It is certified that no wages have been paid to Shri/Smt/Kum.
__________________________ for the period of his/her treatment from ______________ to
__________________.
His/her Identity Card/‟B‟Reg. No. is ________________________________
Signature:
Designation:
Name & Address of the
Beedi/Mine management:
Date:
Certificate of the superintendent of the Hospital
Certified that Shri/Smt/Kum. _____________________ who is employed as
____________________ in the Mine/Beedi establishment of M/S __________________________
has undergone treatment for _________________ in this hospital.
He/She was admitted in the hospital for the said purpose from ___________________ to
______________________ and was discharged on ___________________________-.
He/She needs rest for ________________________ day w.e.f. ____________________.
Signature of the
Superintendent of Hospital
Name:
Address:
Place:
Scheme no. 5
Annexure-I
FORM „A‟
Application form for financial assistance for Kidney Transplantation or allied treatment
To,
The Welfare Commissioner,
Labour Welfare Organisation,
………………………………
Sir,
I herby apply for financial assistance for undergoing Kidney Transplantation or allied
treatment in ………………………………….. (Name of the hospital where the treatment has been
recommended by the Medical Officer, Labour Welfare Organisation). In this connection, I submit my
particulars as under:1. Name of the Applicant in Full
(In Block Letters)
2. Name and address in full of the
Mine/Beedi establishment/Beedi
Contractor/Agent.
3. The date of his/her employment
and total continuous service.
4. Designation or the nature of his/her
employment.
5. His/Her monthly salary/wages (excluding
bonus)
6. (a) Identity Card No. in case of Beedi Workers.
(b) „B‟ Register No. in case of Mine Worker.
Signature of Mine/Beedi worker/Cine worker
Name:
Place:
Date:
CERTIFICATE BY THE MINE MANAGER/OWNER AND IN CASE OF BEEDI WORKER BY
OWNER OF ESTABLISHMENT/CONTRACTOR/AGENT
It is certified that Shri/Smt./Kum. ……………………………………. Is employed in this
mine/Beedi Establishment by me as ………………………………… continuously with effect from
…………………………………….. and information furnished by him/her as above is correct.
Signature:
Designation:
Name and Address of the Mine/Beedi
Management/Contractor.
Date:
Seal of the Mine/Beedi
Establishment
Countersigned by the Owner/Manager of
theBeedi Establishment if the worker is
working under Contractor/Agent.
OWNER/MANAGER
Name:
Designation:
Address:
Date:
CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO
Certified that I have carefully examined Shri/Smt./Kumari ……………………
…………………………….. and found him/her suffering from ………………………..
……………… diseases. In my opinion, his/her admission in the ………………………
……………….. hospital which is recognized by the Govt. of ………………………….
Is absolutely necessary for ………………………………………………………..
His/her Identity Card No. is …………………………………………………
„B‟ Register No. is ……………………………………………………………
Signature:
Name:
Designation:
Name of the Dispensary/Hospital
Dated: ………………
FORM „B‟
Application for grant of subsistence allowance from the Labour Welfare Organisation under the
Scheme for Financial Assistance to Mine and Beedi workers for Kidney Transplantation etc.
To,
The Welfare Commissioner,
Labour Welfare Organisation,
……………………………
Sir,
I herby apply for subsistence allowance and other financial benefits under the scheme for
financial assistance to mine and beedi workers for Kidney Transplantation. I have undergone
treatment for ……………………………….. in ………………………
……………………………………….. (mention the name of the hospital where the treatment has
been taken).
I furnish my particulars as under:1. Name of the Applicant in full :
2. Date of birth/Age :
3. Full postal/residential address of the applicant :
4. Full address of the hospital where
the applicant has undergone treatment :
5. The reference No. and date of the
letter from Welfare Commissioner permitting
him/her to undergo treatment in the above
hospital :
6. Source of receipt of Kidney Name and
full address of the Donor :
7. Amount actually incurred by the Applicant
for treatment (Furnish the details with
supporting bills etc. each bill has to be
countersigned by the hospital authorities
with seal and full signature) :
(a) Kidney charges (Donor‟s) : Rs.
(b) Hospital charges including diet etc. : Rs.
(c ) Charges for Dialysis : Rs.
(d) Expenses for pre and post operation : Rs.
Check ups :Rs.
______________
Total :Rs.
8. Amount claimed as Mode of travel No. of personsAmount
bus/train charges
(a) Date of outward Journey:
(b) Date of inward Journey:
I hereby declare that the particulars furnished above are correct. If any of the particulars
are found to be incorrect, I realize that I will be liable action for suitable action apart from
refund of financial assistance, if any received by me.
Signature of the Mine/Beedi worker
Place:
Date:
CERTIFICATE BY THE MANAGEMENT
It is certified that Shri/Smt/Kum/ ……………………………… is employed in this
mine/Beedi Establishment by me as …………………………….. ( mention designation)
and that his/her wage is ………………………… p.m.
It is certified that no wage have been paid to Shri/Smt/Kum. …………………….
…………………….. for the period of his/her treatment from ……………………….. to
…………………….
His/her Identity Card/‟B‟ Reg. No. is ………………………………………..
Signature
Designation
Name & address of the
Beedi/Mine management.
Certificate of the Superintendent of the Hospital
Certified that Shri/Smt./Kum. ……………………………………… who is employed as
………………………………………… in mine/Beedi establishment of M/s
…………………………………………………… has undergone Kidney transplantation and
treatment/allied treatment in this hospital.
He/She was admitted in the hospital for the said purpose from …………………
……………… to and was discharged on ………………………………….. He/She needs rest for
…………………………….. daysw.e.f. ……………………………..
Signature of the Superintendent of Hospital
Name
Address
Place:
Scheme no. 6
FORM „A‟
Application form for financial assistance for domiciliary treatment of minor diseases like
Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases.
To
The Welfare Commissioner,
Labour Welfare Organisation,
………………………………
Sir,
I hereby apply for financial assistance for undergoing domiciliary treatment of minor diseases
like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases in
………………………………….. (Name of the hospital) where the treatment has been recommended
by the Medical Officer, Labour Welfare Organisation. In this connection, I submit my particulars as
under:7. Name of the Applicant in Full
( In Block Letters)
8. Name and address in full of the
Mine/Beedi establishment/Beedi
Contractor/Agent.
9. The date of his/her employment
and total continuous service.
10. Designation or the nature of his/her
employment.
11. His/Her monthly salary/wages (excluding bonus)
12. (a) Identity Card No. in case of Beedi Workers.
(b) „B‟ Register No. in case of Mine Worker.
Signature of Mine/Beedi worker/Cine worker
Name:
Place:
Date:
CERTIFICATE BY THE MINE MANAGER/OWNER AND IN CASE OF BEEDI
WORKERBY OWNER OF ESTABLISHMENT/CONTRACTOR/AGENT
It is certified that Shri/Smt./Kum. ……………………………………. Is employed in this
mine/Beedi Establishment by me as ………………………………… continuously with effect
from …………………………………….. and information furnished by him/her as above is
correct.
Signature:
Designation:
Name and Address of the Mine/Beedi
Management/Contractor.
Date:
Seal of the Mine/Beedi
Establishment
Countersigned by the Owner/Manager of the Beedi Establishment if the worker is
working under Contractor/Agent.
OWNER/MANAGER
Name:
Designation:
Address:
Date:
CERTIFICATE OF THE MEDICAL OFFICER OF THE LWO
Certified that I have carefully examined Shri/Smt./Kumari ……………………
…………………………….. and found him/her suffering from ………………………..
……………… diseases. In my opinion, his/her admission in the ………………………
……………….. hospital which is recognized by the Govt. of ………………………….
Is absolutely necessary for ………………………………………………………..
His/her Identity Card No. is …………………………………………………
„B‟ Register No. is ……………………………………………………………
Signature:
Name:
Designation:
Name of the Dispensary/Hospital
Dated: ………………
FORM „B‟
Application for grant of subsistence allowance from the Labour Welfare Organisation under the
Scheme for Financial Assistance to Mine and Beedi workers for domiciliary treatment of minor
diseases like Hernia, Appendectomy ulcer, Gynaecological diseases and prostate diseases.
To,
The Welfare Commissioner,
Labour Welfare Organisation,
……………………………
Sir,
I herby apply financial benefits under the scheme for financial assistance to mine and
beedi workers for …………………………… I have undergone treatment for
………………………… (mention the name of the hospital where the treatment has been
taken).
I furnish my particulars as under:8. Name of the Applicant in full :
9. Date of birth/Age :
10. Full postal/residential address of the applicant :
11. Full address of the hospital where
the applicant has undergone treatment :
12. The reference No. and date of the
letter from Welfare Commissioner permitting
him/her to undergo treatment in the above
hospital. :
13. Amount actually incurred by the Applicant
for treatment (Furnish the details with
supporting bills etc. each bill has to be
countersigned by the hospital authorities
with seal and full signature) :
(a) Hospital charges including diet etc. : Rs.
(b) Expenses for pre and post operation
Check ups:Rs.
______________
Total :Rs.
I hereby declare that the particulars furnished above are correct. If any of the
particulars are found to be incorrect, I realize that I will be liable action for suitable action
apart from refund of financial assistance, if any received by me.
Signature of the Mine/Beedi worker
Place:
Date:
CERTIFICATE BY THE MANAGEMENT
It is certified that Shri/Smt/Kum/ ……………………………… is employed in this
mine/Beedi Establishment by me as …………………………….. ( mention designation)
and that his/her wage is ………………………… p.m.
It is certified that no wage have been paid to Shri/Smt/Kum. …………………….
…………………….. for the period of his/her treatment from ……………………….. to
…………………….
His/her Identity Card/‟B‟ Reg. No. is ………………………………………..
Signature
Designation
Name & address of the
Beedi/Mine management.
Date
Scheme no. 7
Application Form for seeking financial assistance for marriage of daughter by
widow of beedi/mine/cine worker
1. Name of the applicant ____________________________
2. Name of the deceased worker and her/his ____________________________
relationship with the applicant
3. Name of the daughter for whose marriage ____________________________
assistance is sought
4. Name of employer/establishment where the _____________________________
beedi/mine/cine worker was working at the time of his death
5. Date of joining the establishment _____________________________
6. Date of death of the worker _____________________________
7. Details of family members of the deceased beedi/mine/cine worker (enclose copy of Identity
Card as proof)
SI. NoNameRelationship with the workerDate of birth
1.
2.
3.
4.
8. Name and address of bridegroom
______________________________________
_________________________________________________________________
9. Date of marriage (enclose copy of invitation card)
_________________________
Declaration: I solemnly declare that the above particulars are correct the best of my
knowledge and belief and in the event of any of the above statements found
incorrect. I will return the full amount of financial assistance of the Welfare
Commissioner.
Place:
Signature of applicant
Date:
Scheme no. 8
FORM OF APPLICATION FOR GRANT OF SUBSISTENCE
ALLOWANCE TO DEPENDANTS OF MINE/BEEDI/CINE
WORKERS UNDER THE DOMICILIARY TREATMENT OF T.
B. SCHEME.
1. Name in full of the workers
2. Name and address in full of the
mine/beedi establishment where
the worker is employed.
3. Designation or the nature of
his/her employment.
4. The date of his/her employment
and period of service at the Mine /Beedi
Establishment before contacting T.B.
5. His/her monthly salary/wages
(excluding bonus)
6. If he/she (patient) is getting
any financial assistance from
any mine management/beedi
establishment or from any source.
If so, state amount with the period.
7. Number of dependants of the
Mine/Beedi worker (patient)
(Dependants include wife/
husband, unmarried children and
step children residing with and
whollydependant on the worker)
8. Name, age, marital status and
relationship of each dependant.
9. Name and address of the
dispensary/hospital where the
worker is being treated.
10. A certificate that the patient is the
only earning member of the family
and has no other source of income
from Mine Manager/Beedi Establishment
or from District Magistrate or any gazette
officer authorized by himor by the
Headman of village Panchayat.
11. Certificate of the Manager of
Mine/Beedi Establishment/
District Magistrate/Headman
of village.
Certified that the statement made by the applicant against items 1 to
8 have been verified and found to be correct.
Manager/Agent/Owner of
Mine/Beedi Establishment
2nd certificate of the medical authority.
Certified that the statement of the applicant against item 9 is correct.
He/she is/has been receiving regular treatment from this
dispensary/hospital.
Signature
Designation
Official Stamp.
APPLICATION FORM FOR CLAIMING
TREATMENT
CHARGES BY MINE/BEEDI/CINE WORKERS
UNDER
THE DOMICILIARY TREATMENT OF T.B.
SCHEME
1. Name in full of the worker
2. The name and address in full of
the mine/beedi establishment
where the worker is employed.
3. Date of his/her employment and
the total continuous service in the
mine/beedi establishment.
4. Designation or the nature of his/
her employment.
5. His/her monthly salary/wages
(Excluding Bonus)
6. The Dispensary/Hospital where the
worker is undergoing Domiciliary
treatment for T.B.
Signature
Date:
Name
ATTESTATION OF THE MANAGER/OWNER
It is certified that Shri /Smt.____________is employed in this
mine/establishment as _____________continuously for
_______________years months. It is certified that the statement made
by the applicant against cols. 1 to 6 above have been verified and found
to be correct.
Signature
Manager/Owner
Name & Address of
Date: SEAL
the
Establishment.
CERTIFICATE OF THE MEDICAL OFFICER
Shri_____________________employed
in_______________mine / establishment and whose
signature/thumb impression is given hereunder, was examined
by me on____________________and was found to be suffering
from T.B. According to my opinion, he/she has to receive
regular domiciliary treatment for T.B.
Date SEAL Signature
Name
Scheme no. 9
FORM OF APPLICATION FOR OBTAINING SPECTACLES FROM THE LABOUR
WELFARE ORGANISTAION.
1. Name :
2. Father‟s Name :
3. Age :
4. Sex :
5. Name of the Mine/Beedi
Establishment/Contractor /Agent
where employed at present. :
6. Name of the owner of the Mine
BeediEstt./ Contractor/ Agent. :
7. Designation. :
8. Date of appointment :
9. Mine/BeediEstt./ Contractor in
which he has worked in the past
with approximate month & year. :
10. Wages received per month :
11. Does he/she already wear the
Spectacles?:
Date:
_____________ _____________________
Signature of the applicant.
CERTIFICATE OF MANAGEMENT/CONTRACTOR / AGENT
12. Service rendered from time to time
S.No
.
Name of
B.R.No
Mine/BeediEstt./Contracto .
r/ Agent.
Perio
d
From
Perio
d
To
Total
Service
.
Signature of the
Manager/Contracto
r/ Agent in token of
having certified the
service period.
It is further certified that he/she gets Rs. ______________ (In words Rupees
___________________________) exclusive of bonus, per month and his economic
condition is so poor that he/she cannot purchase a Spectacles. He/she deserves providing
of Financial Assistance for Spectacles.
Date: ________________
Agent.
Name of Manager/Owner/Contractor
Seal of Management.
CERTIFICATE OF MEDICAL OFFICER OF THE ORGANISATION
It is certified that I have examined Shri/Kum./Smt. _______________________ S/o,
D/o of ________________________ employed ____________________________
carefully and have come to the conclusion that he/she need corrective lenses to improve
his/her vision. The case deserves further examination by an Eye Specialist. He/She is,
therefore, referred to ______________________________________(Name of the Hospital
is to be given) or ____________________________________(Qualified Private Eye
Specialist).
Date: ___________
Name _____________________
Designation _________________
Seal
CERTIFICATE OF THE EYE SPECIALIST
Certified that I have examined Shri/Kum./Smt. ____________________________
S/D/W of ____________________________ aged _________ Sex ______________
carefully and allot the vision/lenses number is under:Right vision
Left vision
I further suggest that the patient should continue to take the following treatment for a
period of __________________________ after this he/she should attend the hospital/clinic
on for re-check.
Date: _____________
Medical Officer / Eye Specialist
SEAL
Scheme no. 10
FORM OF APPLICATION
1. Name in full of the worker:
2. The name and address in full of
the Mine/Beedi Establishment
employed.
3. The date of his employment
and the total continuous service
in the Mine/Beedi Establishment.
4. Designation or the nature of his
employment.
5. His monthly salary/wages (excluding bonus).
6. The Hospital where admission is sought.
7. Whether he was admitted previously under
this Scheme. If so, give date and the
period of his stay and the name of the
Hospital.
Date:
Signature
Name
`
FORM OF APPLICATION
1. Name in full of the worker:
2. The name and address in full of the Mine/Beedi
Establishment employed.
3. The date of his employment and the total continuous
Service in the Mine/Beedi Establishment.
4. Designation or the nature of his employment.
5. His monthly salary/wages (excluding bonus).
6. The Hospital where admission is sought.
7. Whether he was admitted previously under this Scheme.
If so, give date and the period of his stay and the name
of the Hospital.
Signature
Name
Date:
ATTESTATION OF THE MINE MANAGER/OWNER
It is certified that Shri/Smt ………………………………… is employed in this mine as
………………………. Continuously for ……………………… years ……….. months and to
the best of my knowledge and information the particulars give above by him/her are correct.
Date
Seal
Signature
Mine Manager/Owner
Name and address of the
mine
CERTIFICATE OF THE MEDICAL OFFICER
Shri ……………………………….. employed in ………………………. Mine and whose
signature/thumb impression is given hereunder, was examined by me on ……………….
And was found to be suffering from ……………………… accordingly to my opinion his
admission the mental Hospital/MansikArogyashala is not absolutely necessary for
……………………..months/days.
Date
Seal
Signature
Name
FORM OF REGISTER TO BE MAINTAINED IN HOSPITALS WHERE
MENTAL PATIENT HAVE BEEN ADMITTED
SI.
No.
Name
of the
worker
Nature of
employme
nt.
Name
of the
mine
Date of
admissio
n
Nature
of
sicknes
s
Duration
of
retention
Complet
e or
partial
recovery
Date of
discharg
e.
Signatu
re of
the
doctor
Remarks.
Scheme no11.
FORM – „A‟
APPLICATION FOR TREATMENT OF MINE/BEEDI/CINE WORKERS
SUFFERING FROM CANCER
1. Name in full of worker.
2. Name & Address in full of mine/beedi establishment.
3. Name of patient.
4. Age and relationship with the worker.
5. Date of his/her employment and the total continuous service.
6. Designation of the nature of his/her employment.
7. His/her monthly salary/ wages (excluding bonus).
8. The hospital where treatment is sought.
9. Whether the applicant/ dependent had undergone treatment for
Cancer previously? If so, mention the duration of the treatment.
Signature
Thumb impression
Date :
(Name in Block letters)
ATTESTATION BY THE PRODUCER/OWNER OF THE FILM INDUSTRY
Certified that Shri/Smt./Kum.-----------------------------------------is employed in this Industry as
continuously wef----------------------------------------and information furnished by him/her above is
correct to the best of my knowledge and belief.
Signature:
Designatioj with seal
Seal of the Film
Indurstry/owner
Place------------Date--------------
ATTESTATION BY THE MANAGER / OWNER OF THE MINE/BEEDI ESTABLISHMENT
Certified that Shri/Smt./Kum. ________________________________ is employed in this
mine/beedi
establishment as ___________________________ continuously w.e.f.
_________________________
and information furnished by him/her above is correct to the bet of m knowledge and belief.
Signature
Place: ________
Designation with Seal
Date: ________
Seal of the Management
Beedi establishment.
CERTIFICATE BY THE MEDICAL OFFICER OF THIS ORGANISATION
Certified that Shri/Kum ………………………………………… employed in
………………………… and whose signature/thumb impression is given
here
under was examined by me on ……………………………. and found to be
sufferingform cancer. According to my opinion his/her admission/treatment
in a
recognized. Cancer Hospital is absolutely necessary for a period of
…………………………… months.He/She is, therefore, referred to
……..……………………………………. (Name of the Cancer Hospital to be
furnished).
OR
Certified that Shri/Smt./Kum ………………………………………………..
Wife/son/daughter/father/mother of
…….…………………………………………
employed in ……………………………………. and whose
signature/thumb
impression is given here under was examined by me on
…………………………………………. and found Hospital is absolutely
necessary for a period of ………………………………… months. He/She/is,
therefore referred to ………………………………………….. (Name of the
Cancer Hospital to be furnished).
Signature
Name & Designation Date …………Seal
CERTIFICATE OF THE MEDICAL OFFICER OF THE RECOGNISED
CANCER HOSPITAL
Certified that Shri/Smt./Kum ……………………………………………………
who is employed as …………………………………………………….. in the
mine/beedi establishment has been carefully examined and found to be
suffering from Cancer, according to my opinion his/her admission/treatment in
one of the Cancer Hospital is absolutely necessary for a period of
……………………………….. (Approximately).
Or
Certified that Shri/Smt./Kum ….…………………………………………….
wife/son/daughter/father/mother of
……………………………………………… who is employed as
………………………………………….. in the mine/beedi establishment of
…………………………………….. has been carefully examined and found to
be suffering from cancer. According to my opinion his/her admission/treatment
in one of the Cancer Hospital is absolutely necessary for a period of
………………………………… (Approx).
Signature
Date …………………
Name & Designation
Seal
Form – “B”
APPLICATION FOR CLAIMING REIMBURSEMENT OF EXPENDITURE
TREATMENT OF CANCER
To,
The Welfare Commissioner,
Labour Welfare Organization,
_______________________
Sir,
I hereby apply for reimbursement of expenditure for the treatment of
cancer, I/my wife/son/daughter/father/mother have/has undergone
treatment for cancer in …………………………………….. (Mention
name of hospital where the treatment has been taken).
1. Name of the applicant in full
(In block letters)
2. Date of birth and age
3. Full address of the applicant
4. Name of the patient
5. Age and relationship with the worker
6. Name and address of the
Mine management/BeediEstt./ in
which he/she employed.
7. Date of continuous employed
in the Mine/Beedi Establishment
Showing the total continuous service.
8. Is the applicant‟s wife or husband employed in the
Mine/Beediestablishment? Give details.
9. Full address of the hospital where
the applicant/dependent
has undergone treatment for cancer.
10. Please quote reference number date of the Welfare
Date of welfare
Commissioner in which he/she permitted to undergo treatment in the
above hospital.
11. Amount claimed as subsistence
allowance showing the duration
of the claim.
12. Amount actually incurred/claimed
by the applicant for medicines, Furnish
details with supporting vouchers/bills etc.
13. Amount actually incurred/claimed
by the applicant on diet, furnish details
with supporting bills etc.
14. Amount claimed as bus/train charges.
15. Amount claimed as D.A.
I hereby declare that the particulars furnished above are correct to the best
of my knowledge and belief. If any of the particular is found to incorrect,
I realize that I will be liable for suitable action a part form refund of
financial assistance received by me.
Place :
Signature of the applicant
or thumb impression
Date : (Name in block letters)
CERTIFICATE BY THE MEDICAL OFFICER OF THE RECOGNIZED CANCER
HOSPITAL
Certified that Shri/Smt./Kum.
…………………………………………………… who is employed as
…………………………………………………… in the Mine/Beedi
Establishment of ……………………………… has undergone treatment
in this hospital as in-patient/out-patient for cancer with effect form
…………………………………
OR
Certified that Shri/Smt./Kum. …………………………………
wife/son/daughter/ father/mother of Shri/Smt./Kum.
……………………………………… who is employed as
……………………..……………………………… in the Mine/Beedi
Establishment of
……………………………………………………………… has
undergone treatment in this
…………….……………………………………………… hospital as inpatient./ out-patient for cancer with effect from …………………… to
……………………..
Signature of the Medical
Date ……………
Officer of the Hospital
Designation & Seal
CERTIFICATE OF THE MANAGEMENT
Certified that Shri/Smt./Kum. ……...………………………………… is employed in the
Mine/Beedi Establishment as …………………………………………… (mention
designation) and that his/her wage is …………………………. Per month.
Certified that Shri/Smt./Kum. ….……………………………………………… is working
in this Mine/Beedi Establishment/Producer/Owner since ……………….
Certified that no wage has been paid to Shri/Smt./Kum. ………………………… for the
period of his/her treatment from …………………………. To ……………………
Designation with Seal
Seal of the Mine/Beedi
Date :
Establishment
Scheme no. 12
APPENDIX-1
LEPROSY DISEASE
Application for grant of subsistence allowance to dependants of such mine /
beedi workers who happen to be the only earning member of the family having no
other source of income and who are suffering from leprosy and undergoing
treatment as in patient or out patient in recognized hospitals / clinics / dispensaries
and are receiving regular treatment from a medical authority approved by the
welfare commissioner, labour welfare fund organization.
1
Name and address of the mine / beedi workers applicant.
2His / Her designation or the nature of his / her employment.
3 Name and address of the mine / beedi establishment where he / she was
working before being attacked with leprosy.
4 His / Her monthly salary / wages (excluding bonus) prior to being
attacked with leprosy.
5 The date of his / her employment.
6 If He / Her (patient) is getting any financial assistance from the mine
management / beedi establishment or from any source. If so state amount
with period.
7 Number of dependants of the mine / beedi worker (dependants include
wife / husband / unmarried children and step children residing with and
whollydependant on the worker)
8 Name, age, marital status and relationship of each dependant.
9Name and address of the leprosy hospital / clinic / dispensary where the
worker is being treated.
10 Name of owner of the leprosy hospital / clinic / dispensary in question
11 Is He / She being treated as indoor or out doorpatient
12 In case as out door patient whether under treatment of a medical authority
approved by the welfare commissioner, labour welfare fund organization.
13 A certificate that the patient is the only earning member of the family and
has no other source of income from manager, mine / beedi establishment
or from district magistrate or any gazette office or by the headman of a
villagepanchyat in case dependants reside in a village.
14 Certificate of the manager, mine / beedi establishment / district magistrate
/ headman of village panchayat.
Certified that the statement made by the applicant against item
1 to 8 have been verified and fund to be correct.
Manager / Agent / Owner of the
mine/ Beedi Establishment.
2nd certified of the medical authority.
Certified that the statement of the applicant against items 9 to 11 is correct.
He / She is / has been receiving regular treatment as out door patient
in this leprosy hospital / clinic / dispensary with effect from------------------------and the treatment is likely to continue up to-------------------Certified that his / her application for grant of diet allowance was not
recommended before and he has not received diet allowance from the labour
welfare fund.
He / She is under treatment of Dr.------------------------------- approved by the
welfare and cess commissioner labour welfare fund.
Signature------------------Designation---------------Official stamp------------Date---------------If it is subsequently found that any statement made by the applicant is wrong
no claim will be entertained.
Signature or thumb impression of the applicant.
1st certificate of the manager of mine k/ beedi establishment / district magistrate /
headman of village panchayat:-
Certified that to statements made by the applicant against items 1 to 8 have
been verified and found to be correct. The statement against item 13 also verified
by inquiry and found to be correct.
Manager / Agent / Contractor
Scheme no.13
To
The welfare commissioner,
Government of India, ministry of labour,
Labour welfare organization,
Sub: Sanction of Grant-In-Aid for maintenance of our dispensary /
services, for the calendar year --------Sir,
We are maintaining a dispensary / hospital for mine workers and
their families. You are requested to kindly sanction annual grant-in-aid
for the calendar year- --------- for maintenance of our dispensary /
hospital.
2 We are giving following particulars:-
(1) Name and address of the mine.
(2) (i) Whether there is a separate
dispensary for mine workers and their
families.
(ii) (a) if there is separate dispensary for
mine workers and their families furnish the
following information:Total No. of mine workers and their family
members given treatment during the
calendar year i.e.; January to December,--------(b) If there is common dispensary for mine
workers, factory workers, officers and
supervisors including their families, please
furnish the following particulars:(i) No. of mine workers and their family
members given treatment during the
calendar year i.e.; from January to
December, ----------.
(ii) No. of factory workers and their family
given treatment during the calendar year
i.e.; from January to December,-------(iii) Total No. of supervisors and officers of
factory and mine including their family
members who were given treatment during
the calendar year i.e.; January to
December, ------3 (a) Whether the dispensary gives treatment
to members of general
public.
(b) (i) If yes, whether medicines are given
to members of general public
(ii) total No. of members of general public
given treatment including medicines during
the calendar year from 1st January to 31st
December, -----4 Percentage of patients treated:(a) Mine workers and their family members
(b) Factory workers / supervisors / officers
including their family members
(c) General public (% to be given if
medicines are issued to them)
5 No. of mine workers
6 No. of factory workers, supervisors &
officers working in mine and factory (this
information will be given if there is a
common dispensary.)
7 Total expenditure incurred during the
calendar year from January to December,------:(a) Establishment
(b) Medicines (spl. Treatment + medi.
Disp.)
TOTAL:8 We are enclosing herewith the following
documents:(i) certificate of chartered accountant
regarding expenditure incurred on
establishment and on purchases of
medicines on Performa –B
(ii) Statement showing the production /
consumption of limestone / dolomite and
cess amount paid on the above quantity in
respect of each month from January to
December, -----The above documents have been signed and
stamped.
Yours faithfully,
Signature
Designation: Director (Operation)
Seal
MINISTRY OF LABOUR
W.V. SECTION
Check-list for proposal to the ministry for sanction of grant-in-aid in favour of the
mine management for purchase of hospital equipment etc.
……..
1.
Name and address of
the mine management.
2.
Name and location of
the dispensary/hospital
maintained by the mine
management for the
benefit of their mine
workers.
3
No. of mine
workers/factory
workers/other local
people(including family
members) who are
allowed treatment from
hospital/disp.
4
No. of mine
Years
worker/factory
workers/other local
people (including family
members) treated in the
hospital/disp. Three
years proceeding the
year in which proposal is
made.
i) No. of mine workers
ii) No. of factory workers
iii) No. of local people
5
Whether treatment
charges are received on
the treatment of nonminers, if so, amount
received during three
years preceding the
years in which proposal
is made.
Mine workers
Factory
workers
Supervisors
and officers
of mines
and factory
Years
Years
6
Cess paid by the mine
management in each of
the year during three
years preceding the
year in which the
proposal is made
Years
1.
2.
3.
Years
7
Grant-in-aid received by
the mine management
scheme-wise and year
wise from the Labour
Welfare Organization
during three years
preceding the year in
which the proposal is
made
i) Grant-in-aid for
maintenance of
dispensary/hosp.
services
ii) Grant-in-aid for
Republic Day
celebration.
iii) Grant-in-aid for
Independent Day
iv)
Years
Years
8
9
v)
vi
A copy of the inspection
report of the
disp./hospital
maintained by the mine
management for the
year preceding the year
in which proposal is
made.
A copy of agenda and
minutes, of the S.A.C.
meeting in which
proposal has been
recommended by SAC.
10 Name of the item(s)
Years
proposed to the
purchased.
11 Cost of item(s)
proposed to be
purchase.
12 Copy of quotation to
indicate the cost of
item(s)
13 Sanctioned budget grant
under “Health –Grant-inaid “during the financial
year (indicate provision)
made in R.E. also in
case the same have
been sent to the Ministry
at the time of
submission of the
proposal.
1. Sanctioned
budget grant for
2. R.E.
14 Expending incurred out
of the sanctioned budget
grant/proposed R.E.
under the Head "Grantin-aid” at the time of
sending the proposal.
15 Expenditure committed
under the Head “Health
Grant-in-aid” as in the
date of submission of
this proposal (indicate
item-wise)
16 Balance in hand to meet
the expenditure interalias for the proposal
being sent to the
Ministry.
17 Proposed manager of
spending the balance
provision(indicate item-
Rs.
Rs.
Rs.
wise)
i) Grant-in-aid for
maintenance of
hospital/disp. Services.
ii) Grant-in-aid for
purchase of Ambulance
Van
iii) Grant-in-aid of
purchase of hospital
Rs.
Rs.
equipments.
iv)
v)
vi)
18 Rule/scheme under
which the proposal is
covered
19 i) Whether the mine
management has
already ambulance Van
ii) Where these
purchased by Grant-inaid L.W.O.
iii) If yes, give reasons,
as to why the
management needs
another ambulance Van
and why grant-in-aid
should be given by
L.W.O.
20 i) Whether the
management already
has in the
dispensary/hospital the
equipment for which
grant-in-aid is being
proposed.
ii) Where these
purchased by Grant-inaid from L.W.O.
iii) If yes, give reasons
Rule 37 of the Limestone/Dolomite
Mines Labour Welfare Fund
Rules, 1973.
as to why the
management further
need the equipment(s)
and why grant-in-aid
should be given by
L.W.O.
21 i) List of other request
from mine management
for grant-in-aid for
purchase of ambulance
Van/equipment pending
with Welfare
Commissioner indicating
date of receipt.
ii) In case this proposal
has been
submitted out of turn
indicate reasons in
detail.
Welfare Commissioner
Scheme no. 14
APPENDIX-I
1 Name and address of the
limestone and dolomite mine.
2 No. of workers and their
families to be benefited in the
proposed scheme.
3 Extent of mechanization.
4 Distance from housing colony
to the nearest hospital.
5 The distance between the
general hospital to the mine
hospital / dispensary
6 Month-wise production for last
three years.
7 Total cess paid for the last 3
years (year-wise figures).
8 Total cost of ambulance van
proposed to be purchased.
9 Other relevant particulars
justifying for the purchases of
ambulance van.
APPENDIX – II
STAMP
Agreement between ----------------------------------------------------------------------------------
And
President of India
This agreement made this------------------------------------------------------------------Day of ----------------------------------- one thousand nine hundred ninety ------------------------------------Between----------------------------------------------------------------------------------------------Ltd., a limestone / dolomite mines company recognized under the
companies Act. 1956 /
(1) --------------------------------------------------(2)-------------------------------------------(3)----------------------------------------------------Partners / proprietors of-----------------------------------------------of limestone / dolomite mines and having its
registered
Office at ------------------------------------------------------------------------------------------Carrying in business under the firm and style of ----------------------------------------------------------------at-------------------------------------------in the town of ------------------------------------------and having its /--------------------------------------------
-----------------------------------------------------Of the state of----------------------------hereinafter referred to as the applicant / the applicant which terms shall
unless excluded by or repugnant to the subject or context include (its successor and
permitted assign) (all partners of the said firm and their respective heirs, executors,
administrators and the permitted assign of the said partners ) of the one part and
the president of India (hereinafter called the “government” which terms shall
unless excluded by or repugnant to the subject or context include it successors and
assign) of the other part.
WHEREAS the “Application / the application” has / have applied for
sanction of grant-in- aid under rule 37 of the limestone and dolomite mines labour
welfare fund rules 1973 and the “Government” have sanctioned Rs -------------------------------------------------------------------------------------------------------(Rupees-----------------------------------------------)
only as subsidy for purchases of the following equipments for improving this
dispensary
at-------------------------------------------------------------------------------------------
(2)
Maintained for their limestone miners and their dependants vide letter No.-----------------Of government of India ministry of labour, New Delhi
ITEMS
COST
1
2
3
4
Now this indenture witness as follows:
1 The payment of the above grant-in-aid shall be subject to the
following conditions.
(a) That the work or which the grant is made is duty and promptly
executed and the money is actually utilized for the purpose for
which it is granted.
(b) That the date on which the grant is calculated are in accordance
with facts
(c) That any particulars which the central government may from time to
time require for the proper discharge of this responsibilities are
promptly supplied
(d) That all necessary facilities for inspection are accorded to persons duly
authorized by the central government for the purpose of clause (A) or
for checking the correctness of any particulars supplied under clause
(C) or for the collection of any such particulars
(e) That proper accounts of the money granted are kept and are submitted
for audit by such persons as the central government may authorized in
this behalf
(f) That an additional statement of accounts together with a certificate of a
registered accountant or other recognized body of auditors to the effect
that the accounts are correct, is furnished by the grantee.
(g) The agreement shall remain in force until the ambulance van is
declared unfit for use by the regional transport authority.
(h) The management shall send an annual certificate on of before 15th of January every
year to the effect that the van is being utilized as ambulance for the welfare of the
mine workers. A proper log book is being maintained until the van is declared unfit
2 The fund shall be released in one lump sum and the money shall be
utilizedfor the aforesaid purpose within one month of the released of
the fund as stipulated (1) above
3 In the event of violation of any condition imposed under (1) above, the
applicant owner shall be liable to pay central government a sum of Rs.---------------------------------- (Rupees ------------------------------------)
By way of interest @ 14% per annum in addition to refund of the entire
remaining grant-in-aid
IN WITNESS WHEREOF the parties hereto have signed this deed on the day and
year first above written.
EXECUTED BY Shri-------------------------------------------------------------------Welfare commissioner, beedi workers welfare fund / iron ore / manganese
ore / chrome ore mines labour welfare fund / mica mines labour fund / limestone
and dolomite mines labour welfare fund for and on behalf to the president of India
in the presence of --------------------------------------------------------------------------------------------------------------------------------In case of companies only. COMMON DEAL FO M / S-----__________________________________________________________
Affixed under resolution of the board of directors dated --------------------------Affixed in the presence of Shri ------------------------------------------------------------------------- Director and Shri -----------------------------------------------------Secretary of the company
CHECK-LIST FOR PROPOSAL TO THE MINISTRY FOR SANCTION OF GRANT IN AID IN FAVOUR OF
THE MINE MANAGEMENTS FOR PURCHASE OF AMBULANCE VAN
1. Name and address of the mine
management
2 Name and location of the dispensary /
hospital maintained by the mine
management for the benefit of their mine
workers
3 No. of mine workers / factory
workers and other local people (including
family members) who are allowed
treatment from hospital / dispensary
4 No. of mine workers / factory workers
and other local people (including family
members) treated in the dispensary
during three years preceding the year in
which proposal is made
5 Whether treatment charges are
received on treatment of non mines, if so,
proceeding the year in which proposal is
made
6 Name of the items proposed to be
purchased
7 Cost of the items proposed to be
purchased
8 Copy of quotation to indicate the cost
of items in duplicate.
9 Cess paid by the mine management in
each of the year during 3 years
preceding the year in which proposal is
made
10 Grant-in-aid received by the mine
management in each of the year during
the three year preceding the year in
which proposal is made (please mention
scheme wise and year wise).
11 A copy of the inspection report of the
dispensary / hospital maintained by the
mine management for the year preceding
the year in which proposal is made.
12 A copy of agenda and minutes of the
S. A. C. meeting in which proposal has
been recommended by S. A. C.
13 Sanction budget grant under the head
“Health-grant-in-aid” during the financial
year (including provision made in R. E.
also in case at the time of submission of
proposal.)
14 Expenditure incurred out of the
sanctioned budget grant / proposed R. E.
under the “Grant-in-aid” at the time of
sending the proposal.
15 Expenditure committed under the
head “Health-Grant-In-Aid” as on the
date of submission of
this proposal (indicate item wise.)
16 Balance in hand to meet the
expenditure inter-alias for the proposal
being sent to the ministry.
17 Proposed manner of spending the
balance provision (indicate item wise.)
18 Rules / scheme under which the
proposal is covered.
(1) Whether the mine management
already has ambulance van (s)
(2) Were these purchased by Grant-InAid from L.W.O.?
(3) If yes, give reason as to why the
management needs another ambulance
vans and why grant in aid should be
given by L.W.O
19 Whether the management already
has in the dispensary / hospital the
equipments for which grant-in-aid is
being proposed (2) were these
purchased by grant-in-aid from L.W.O (3)
if yes, give reasons, as to why the
management further needs the
equipments and why grant-in-aid should
be given by labour welfare organization.
20 (1) List of other request from mine
management for grant-in-aid for
purchase of ambulance van / equipments
pending with welfare commissioner
indicating date of receipt.
(2) In case this proposal has been
submitted out of turn (indicate reason in
detail
APPLICATION FOR AMBULANCE VAN
1 Name and address of the limestone and dolomite mines
2 No. of workers and their families to be benefit in the proposed
scheme.
(a) Mines workers.
(b) Factory workers.
(c) Local people.
3 Extent of mechanization
4 Distance from housing colony to the nearest Hospitals
5 Name and location of dispensary / hospitals maintained by mines
management for mines workers.
6 The distance between the state general hospital to the mine
hospitals / dispensary.
7 Whether treatment charges received on the treatment of non
mines. If so amount received during last 3 years/
8 (a) whether the mine management already has ambulance van
(b) Were there purchased by grant-in-aid from welfare organization.
(c)If yes, give reasons for replacement.
9
Total percentage of mine workers treated during the preceding
years from the total patients treated.
10
Month wise production for last 3 years.
11
Total cess paid for the last 3 years (year wise figure).
12
Total cost of ambulance van proposed to be purchased.
13 Other relevant particular justifying for the purchase of
ambulance van.
Scheme no. 15
APPENDIX – I
Application form for the grant of benefit under the mica / iron ore, manganese ore and chrome
ore and limestone and dolomite mines fatal and serious accident benefit scheme.
*******
To,
The welfare commissioner,
Labour welfare organization,
Subject:-
Grant of benefit under the mica / iron ore, manganese ore and chrome ore and
limestone and dolomite mines fatal and serious accident benefit scheme.
*******
Sir,
I beg to apply for the grant of benefit under the mica / iron ore, manganese ore and
chrome ore and limestone and dolomite mines fatal and serious accident benefit scheme.
The requisite particulars are given bellows:(a) Name of the applicant
(b) Relationship with the worker
(c) Address
(d) Name of the worker with father‟s / husband‟s name
(e) Name of the mine where employed
(f) Post on which employed
(g) Place where the accident took place
(h) Date and time of the accident
(i) Nature of accident
(j) Whether the accident was fatal or it made the worker totally and permanently
incapacitated?
(k) No. of school going children
Sl.
Name of
Remarks
No. the child
Sex
I solemnly affirm that:
Age Name of the
institution in
Which studying
Class in
which
Studying
Date
of admission
(i) The particulars given above are true
(ii) I am a widow / widowers of the deceased worker and have not remarried
(iii) I am dependent on the deceased worker
(iv) I am the father / month / son / daughter / unmarried or widowed
sister/ brother of the deceased worker
(v) I am the guardian of the deceased worker
(vi) No girl mentioned in (k) above is married
*Strike off whichever is not applicable
Signature of L. T. I. of the applicant.
Certificate to be signed by the head of the educational institution.
Certified that the particulars given in col. (k) are correct. The student
are continuing in their classes
Date Place Signature of the headmaster
Seal
Certificate to be signed by the Mukhia of the gram panchyat or the
manager or agent of the mine concerned.
_________
Certified that the particulars given by the applicant are true and correct
Signature of the Mukhia of panchayat/
Manager or agent of the mine.
Name
Address
Designation
Name of the mine or village
Seal of the Mukhia
Manager or agent Date.
(iv)
Certificate of the superintendent of any of the hospitals of the mica / iron
ore, manganese ore and chrome ore and limestone and dolomite mines
labour welfare fund or the medical officer of the mine hospital.
---------Certified that the worker Shri / Smt. _______________________________
Employed in ____________________(Mine) as_______________________
Was involved in the accident__________________at___________________
(Mine) on ___________________at (time)
___________________________
and has died / has been permanently and totally incapacitated.
Place
Date
Seal
Signature of medical officer
Scheme no. 16
FORM OF APPLICATION
1. Name in full of the worker :
2. The Name and address in full of the
Mine/Beedi establishment where the
worker is employed.
3. The date of his employment and total
Continuous service.
4. Designation or the nature of his employment
5. His monthly salary/wages(excluding bonus)
6. The Hospital where admission is sought.
7. Whether he was admitted previously in the
reserved bad under this scheme. If so give
date and the period of his stay and the
name of the hospital.
Signature
Name
Dated:
ATTESTATION OF THE MANAGER/OWNER
It is certified that Shri/Smt.______________________________is employed in this
Mine/Beedi establishment as ______________________continuously for
______________years__________months and to be best of my knowledge and information the
particulars given above by him/her are correct.
Signature
Date
Seal Manager/Owner
Name & Address of the establishment.
CERTIFICATE FROM THE MEDICAL OFFICER
Shri___________________________employed____________________in establishment and whose
signature/thumb impression is given hereunder, was examined by me on
______________________and was found to be suffering from _________.According to my opinion
his admission in one of the reserved beds in this hospital for Mine/Beedi workers is/is not absolutely
necessary for ____________________days(approximately).
Date
Seal
Signature
Name
FORM OF REGISTER TO BE MAINTAINED IN HOSPITALS
WHERE BEDS ARE RESERVED FOR MINE/BEEDI WORKERS
____________________________________________________________________
S. Name Nature of Name of Date of Nature Duration CompleteDate of Signature Remarks
No. of the employ- the estab- admission of sick of reten- or partial discharge of the Dr.
Workermentlishmentnesstionrecovery
This agreement made on the______________day of _________198 between the medical
officer in charge__________Hospitalat__________here in after called the hospital (which expression
where the context so admits shall include successors or assigners on the one part and the president of
India, acting in the premises through the welfare Commissioner for Labour Welfare Fund here in
after called “the Central Government(which expression shall, where the context so admits, include
his successors and assigners) on the other party whereby it is agreed as follows:(1) This agreement is initially for a period of one year with effect from _________.This
agreement may be renewed for a further period upon such terms and conditions as
may be mutually agreed upon.
(2) Agrees and undertakes to reserve ______________bed (_________) beds in the
hospitalat___________here in after called the hospital for admission of patients
requiring hospital treatment for Mine/Beedi Workers at a cost of
Rs.______________per bed per year (here in after called the reservation
charges).The reservation charges at the rate shall be payable by the Central
Government for the period such beds are reserved.
(3) The Welfare Commissioner, Labour Welfare Fund will cause to be paid from
Welfare Fund reservation charges in the beginning of every three months with effect
from the date of this agreement.
(4) The occupants of such reserved beds will receive full facilities of the hospital, staff,
Of the equipment, medicines, nursing, food and other amenities of the hospital such
as ambulance etc. and will receive the same treatment in all ways as other patients in
the hospital.
(5) Reservation charges of Rs. ___________(Rupees______________________) will
include all the expenditure incurred routine and special medicines, injections, etc.
required as well as charges for X-Ray operations.
(6) Admission to the reserved beds will be arranged through Welfare Administrator or
any other officer authorized by the Welfare Commissioner of the Labour Welfare
Fund in consultation with Medical Officer in charge of the hospital at
_________________.
(7) Admission of the patient shall not be refused by the Medical officer-in-charge of the
hospitalat_____________if the number of patients among the Mine/Beedi Workers
is less than the number of beds reserved, nor such admission to Mine/Beedi workers
refused, even if the number of such patients exceed______________in the beds are
otherwise vacant in the Hospital.
(8) Inspection of the reserved beds in the hospital may be made by the Welfare
Commissioner Labour Welfare Fund or any other person authorized by him with or
without notice to Medical officer in charge of the hospital.
(9)Progress report on every patient admitted to the reserved beds will be forwarded by
the Medical officer in charges of the hospital to the Welfare Commissioner, Labour
Welfare Fund every month by the 10th of the next month and cases of death of any
persons admitted under this scheme will be reported within 24 hours of the
occurrence.
Scheme no 1
FORM OF HOUSING
FORM OF APPLICATION FOR GRANT OF SUBSIDY UNDER REVISED INTEGRATED
HOUSING SCHEME (RIHS) – 2005, FOR BEEDI WORKERS
ETC.
TO,
THE DISTRICT COLLECTOR /DEPUTY COMMISSIONER,
DISTRICT MAGISTRATE
________________________ (Name of the District)
Sir,
PART-I
1.
(a) Name of Beedi/Mine Workers with his/her
Father‟s/Husband/s Name with complete Present
Postal Address; and
(b)Name & Address of Establishment, if employed
2.
Date of Birth & Age on the date of application :-
3.
Date of appointment as per „B‟ register:-\
4.
Monthly average income of the family :-
Photographs of
beneficiary with
his/her spouse
and
signature/thumb
impression on
their
photographs
(Should NOT exceed Rs. 6500/- in case of Beedi Workers &Rs. 10,000/for Mine workers)
5.
Details of Provident Fund A/c No. or Identify Card No.
(Enclose a Xerox copy):6.
Details you own nay house in your name or in the name
Of your spouse of any of your dependent sons/daughters
If so, give details:-
7.
constructed :-
Complete details of the Plot etc. where the house is proposed to be
(i) Is the plot/site in your possession or jointly/severally with other
members of his/her family, so on what term:-
A. Details of settlement deed, if any :B. Area of Plot :C. Site Survey No. :D. Name of Village/Town/City:E.Post Office with Pin Code :F. Taluka/Mandal :G.Name of District/State :8.
A) Details, if any house has been provided to the applicant/ by spouse the
State/Central Government under any other housing scheme.
B) Have you or your spouse has earlier availed
Any subsidy under BYOHS/GHS/EWS Housing Scheme:-
9.
Is the title of the plot/site clear and free from all encumbrances?
(Enclose relevant documents concerned revenue authorities) :10.
Enclose estimate of the cost of construction with a layout plan approved by the
concerned authorities :
11.
Details of Employees contribution of Rs. 5,000/- Amount Rs.
a) By Cash/Cheque/DD
b) Cheque/DD No. & Date
c) Name of Bank
12.
If the plot/site is allotted by the State Government or local bodies,
(Attach attested copies of relevant documents from the concerned authorities
13. Do you agree to the execution of the agreement prescribed under the
scheme?
14.a) Do you agree to produce a surety as required under the scheme?
b) If yes, Name and Occupation of the surely with full postal address:(Surety should possess property valuing not less than Rs. 45,000/-. If it is
not possible to arrange a surety the applicant shall mortgage that land on
which he/she proposes to construct a house in the prescribed form).
15. Does the applicant belong to SC/ST/OBC?
If so, attach a copy of the Certificate from the competent authority.
I certify that the particulars given in this application are true to the best of my
knowledge and belief.
Place:Signature/Thumb impression of the Beedi/Mine Worker
Date:-
Verified the above particulars and found correct. He/she fulfills the
eligibility requirements of obtaining the subsidy for construction of a house under
the Revised Integrated Housing Scheme, 2005 of Beedi Workers etc.
(BYOHS/GHS) implemented with the subsidy of Government of India, Ministry of
Labour & Employment. Hence his/her name has been included in the list of
beneficiaries.
Place:Date: SIGNATURE OF THE DISTRICT COLLECTOR/
DISTRICT MAGISTRATE/DEPUTY COMMISSIONER*
(With Name & Officer Seal)
* NOTE :- The certificate on the Application Form is to be signed by the District
Collector / Dist. Magistrate/Deputy Commissioner of the concerned, himself.
Signature of any other Officer nominated by the DC/Dy. Comm. / DM or
otherwise, would NOT BE ACCEPTED.
PART-II
CERTIFICATE OF THE MANAGEMENT OF BEEDI/MINE
ESTABLISHMENT
I am certifying that applicant is an employee of this Beedi/Mine
Unit/Establishment from ______________ (Date of appointment) as the B.
Register _________________ No. _______________ and still working as Beedi
worker to the best of my knowledge and belief. I recommend that the application
may be considered favorably.
Place:Signature of the Manager/Owner/Agent/Contractor (with Seal)
Date:-
Note: - In case the Contractor/Agent signs the certificate, the Manager/Owner of
the Beedi/Mine Establishment has to counter sign. Otherwise, the above certificate
will not be treated as valid.
CERTIFICATE OF THE VILLAGE OFFICER / SUB REGISTRAR
(REVENUE AUTHORITY)
It is certified that after investigation from the records of the Sub-Registrar
___________________ and relevant Revenue and / Court records and form the
information gathered from the sworn declaration made by Shri/Smt.
_________________ and that ______________________ Survey No.
________________________ / Vacant Plot No. ___________________
Measuring ___________________ Sq.Yards/Meters at in the limit of
________________________________ is the absolute property of Shri/Smt.
______________________________________ Son/Wife/Daughter of Shri/Smt.
______________________________________ and * joint family property* / not a
joint family properly. The said property is free from all encumbrances &
attachments and Shri/Smt. ______________________________________ has
clear and marketable title to the property. (* Strike off whichever is not
applicable).
Place:
Date:
Signature:
Designation:
Seal
Note:1. Certificate should be obtained from the concerned revenue authorities and
from the Gram Panchayats.
2. In case where the worker possesses plot/site jointly/severally with other
members of the family, there should be settlement deed in support of no objection
for construction of house.
LIST (IN DUPLICATE) FOR VERIFICATION & INSPECTION OF
APPLICATIONS/APPLICANTS UNDER THE “BUILD YOUR OWN HOUSE
SCHEME” (BYOHS) FOR THE REVISED INTEGRATED HOUSING SCHEME-2005
(RIHS-2005) FOR THE BEEDI/MINE WORKERS.
NAME OF THE FUND ___________________________________________
SL.NO. OF APPLICATION __________________________________________
1. Name of the applicant : Shri/Smt./Miss
2.Father/Husband‟s name :
3. Applicant‟s residential address :
4. Whether working in Management/Gharkhatta :
5. Name and Address of the Management/Contract :
6. a) Whether he/she or spouse owning a house? : YES/NO
b) If yes, details of benefits availed under any Scheme:
7. Identity Card and/or P.F. A/c No. :
8. Monthly family income of the applicant :
9. Whether the application in the prescribed form? : YES/NO
10.
Whether all the Columns in the application form filled : YES/NO
11. Has the Certificate countersigned by the Management or Contractor or Agent
Filled-in and signed”?
12. Does the applicant belong to GEN CAT./SC/ST/OBC :
13. Status of the land (if owned individually, jointly or ancestral
or allotted by the State Govt.
14. If the land owned jointed by other members of the family, letters of No
Objection by other members of the family have been enclosed: YES/NO
15. Whether the site plan, building plan and specification with estimates
Enclosed i.e. the cost of construction : YES/NO
16. Has he/she filled the sale/transfer/settlement deed : YES/NO
17. It the area NOT less than 60 Sq. Yards. : YES/NO
18. Whether he/she put in a service of 1 (one) year : YES/NO
19. Whether he/she sanctioned any subsidy for the house previously: YES/NO
20. Cost of proposed construction of house (should not exceed Rs. 1 Lakh):
21. Has the applicant deposited Rs. 5,000/- along with the application : YES/NO
(Cash/demand draft No., date, amount etc. and other details)
22. Has the Non-encumbrance certificate (NEC) been enclosed along: YES/NO
with the details of boundaries of the proposed site and transaction deed:
23. Life span of the house(s)
It is certified that the details given in the check list have been got verified and found to be
order. He has not availed any subsidy under any Scheme, earlier. The applicant or his/her spouse
does not own a house in his/her name. The applicant is eligible to avail benefits of housing
subsidy under the RIHS, 2005.
Place:Date: SIGNATURE OF THE DISTRICT COLLECTOR/
DISTRICT MAGISTRATE/DEPUTY COMMISSIONER*
DETAILS OF THE INSPECTION AUTHORITY
No. ____________________
Date ____________
FIRST CERTIFICATE OF INSPECTION (FIRST PHASE)
With reference to the letter No. _____________ dated _______________ from the
______________________________________ (details of the concerned DC/Dy. Comm./DM) in
respect of administrative approval granted by the Director General Labour Welfare, Ministry of
Labour & Employment, Government of India, New Delhi vide its sanction letter No.
_____________ dated ________________ for ____________ houses for Beedi/Mine Workers, I
am to inform that the houses constructed by the following Beedi/Mine Workers under the
Revised Integrated Housing Scheme, 2005 for Beedi workers etc., have been inspected by me
from ___________ to ______________ (Specify the dates of inspection) and found that the
houses are being constructed in accordance with the terms & conditions of the Scheme and
specifications mentioned in approved lay-out plan and the construction of these houses have
reached up to roof level.
SI.NO
Name of Father/Spouse’s
Name of Worker
Address
2. It is, therefore, recommended that these beneficiaries have become eligible for the
secondinstallment of subsidy @ Rs. 20,000/- per tenement. The second installment in respect of
the each of the above ______ (No. of houses) may kindly released.
Date:
Place:
(Name & Designation of the inspecting Authority)
(With Office Seal)
DETAILS OF THE INSPECTION AUTHORITY
No. ____________________
Date ____________
SECOND CERTIFICATE OF INSPECTION (FIRST PHASE)
With reference to the letter No. _____________ dated _______________ from the
______________________________________ (details of the concerned DC/Dy. Comm./DM) in
respect of administrative approval granted by the Director General Labour Welfare, Ministry of
Labour & Employment, Government of India, New Delhi vide its sanction letter No.
_____________ dated ________________ for ____________ houses for Beedi/Mine Workers, I
am to inform that the houses constructed by the following Beedi/Mine Workers under the
Revised Integrated Housing Scheme, 2005 for Beedi workers etc., have been inspected by me
from ___________ to ______________ (Specify the dates of inspection) and found that the
constructed of under mentioned houses has been COMPLETED as pr the plan & specifications
of the Scheme. These houses are durable to sustain a life span of minimum 20 years, in
accordance with the terms & conditions of the Scheme.
SI.NO
2.
Name of Father/Spouse’s
Name of Worker
Address
These houses have been complete in all respect and Central Subsidy of Rs. 40,000/- has
been fully released to the beneficiaries in respect of above _______ (No. of houses) and has been
utilized in accordance with the terms and conditions of the Scheme.
Date:
Place:
(Name & Designation of the inspecting Authority)
(With Office Seal)
REVISED INTEGRATED HOUSING SCHEME-2005 FOR BEEDI WORKERS ETC.
(Utilization Certificate in Form GFR 19-A)
NAME OF THE DISTRICT _________________________ STATE ___________
a) Unspent Balance from Previous Year
:
Rs. _________ Lakhs
b) Grants received during the year
:
Rs. ____________
Certificate that a sum of Rs. ____________ Lakhs was received by the D.C./D.M./Dy.
Comm. ____________ (Name of the District) as Grants in Aid during the Year
____________ as per details given in the margin from the Centre and the State Govt. As
housing Subsidy, amounting to Rs. ____________ Lakhs, Further a sum of Rs.
____________ Lakhs being inspect balance was allowed to be brought forward for
utilization during the current year ____________. The receipt on account of the
Workers‟ Contribution during the current year ____________ was Rs. ____________
Lakhs.
c) Misc., receipts of the Authority
:
d) Receipts on account of Worker‟s Contributions
:
e) Interest receipts
:
Total Funds Available (a+b+c+d)
:
Letter No. Date Central Govt.
:
State Govt. Total
It is also certified that out of the above mentioned total funds, together with the receipt of
worker‟s contribution, they total funds of Rs. ___________ Lakhs available with the
____________ (Name of the District & State), a sum of Rs. ____________ Lakhs has been
utilized by ____________ (Name of the Agency) during the financial year ____________ for the
purpose for which it was sanctioned. It is further certified that the unspent balance of
Rs. ____________ Lakhs remaining at the end of the financial year
would be utilized for the purpose next year.
3. Certified that I have satisfied my self that the conditions
on which Grant-in-Aid was sanctioned have been duly
fulfilled/are being fulfilled and that I have exercised the
following checks to see that the money has been actually
utilized for the purpose for which it was sanctioned.
i)
ii)
SIGNATURE OF DC/DM/Dy. Comm. Of the Concerned District
Date :
(with Name and Officer Seal)
Scheme no. type 2
Questionnaire to ensure the Safety of the proposed
Houses under the Housing Scheme to be answered by
the Applicant Mine Management.
1. If the Site falls over a Limestone/Dolomite bearing land, whether
any working
exist?
2. If virgin, whether management have any intention for working
the scheme during the life
of the low cost houses (type II Houses)
3. If developed whether:a. The workings are stable :
b. The workings are affected by fire? :
c. The workings are accessible by fire? :
d. The management intends to extract :
e. The plan showing the workings and site is certified to be correct?
f. The depth of cover is adequate? :
g. The strata is competent for its stability:
4. If the proposed site is over a caved out area :
a. When was depillaring completed? :
b. Whether the ground is considered settled:
If so how the management has ensured if
c. Whether any under ground sport level have
Been maintained?
d. In case of further extraction of underlying:
Seams, proposal may not be accepted
e. Whether the death of cover is adequate:
For stability of the houses?
f. Whether management propose to extract:
Underlying seams in conjunction with
Showing which will maintain the strata stable?
5. Whether an undertaking to the effect that in
Case the houses are damaged because of mining
Activity(s), the management will pay adequate
Compensation to Central Govt. is attached.
6. Whether construction will be done 400 meter :
Away of the working place so that damage by
Blasting is eliminated.
Signature:
Name:
Designation:
FORM OF RECREATION
Scheme no . 2
PROVIDED ALWAYS AND IT IS HEREBY
AGREED THAT
1 In the event of violation of any of the afore
mentioned conditions by the second party, the
second party, shall be liableto pay to the first
party the amount of Rs. ___________ (together
with interest at the government rates for the time
being in force) on demand without a demur.
2 This bond is given for the performance of an
act in which thepublic are interested.
IN WITNESS here of the common seal of the
company hashereinto been affixed the day and
year first above written.
Signed, sealed and delivered by Shri.
Welfare and cess commissioner, limestone and
dolomite mineslabour welfare fund, for and on
behalf of the president of India in the presence of
1
2
The common seal of the above named has
hereinto been affixed by the direction and in the
presence of
1
2
AGREEMENT
This agreement is made this the ______________
day of one thousand nine hundred and
________________between the president of India
hereinafter referred to as the first party which
expression shall unless excluded by or repugnant
to the subject or context including his successors
and assigns of the one part and having their
registered office at ____________ in the town of
____________________ hereinafter referred to as
the second party which expression shall unless
excluded by or repugnant to the subject or context
be deemed to include their successors and assigns
of the other part.
WHEREAS a sum of Rs. ____________ (rupees
________________) only has been granted by the
first party from the limestone and dolomite mines
labour welfare fund under section 5 (2) (c) of the
limestone and dolomite mines labour welfare fund
act, 1972 to the second party for setting up of a
sports ground at
AND WHEREAS the second party has agreed to
accept the said grant.
NOW THEREFORE THIS AGREEMENT
WITNESSETH and the parties hereto hereby
agree as follows:1 That all the right in respect of the land on which
the sports
ground is to be set up have been acquired by the
mine owner‟s
and shall continue to rest with them for a period
of not less
than ten years.
2 That as the said sports ground shall be set up on
the piece of
land marked “A” in the enclosed plan attached
hereto as
annexure I and according to the specifications as
given in
annexure II :
FORM OF APPLICATION FOR GRANT-INAID FROM THE LIMESTONE AND
DOLOMITE MINES LABOUR WELFARE
FUND TOWARDS PROVISION OF SPORTS
GROUND IN THE LIMESTONE AND
DOLOMITE MINING AREA.
------------1 Name of the mine with
postal address
Thane
District
State
2 Name of owner with address
3 No. of workers employed
Male Female
4 Total population in the mine
5 No. of houses provided
Single
roomedroomed .
tenementstenements
Double .
(a) by the management
(b) under the housing scheme of the fund
(c) under any other scheme
6 Is the site proposed for the sports ground
centrally situated ?
(Site plan showing locations are to be given)
7 Estimates of cost for preparing the
sport ground.
(Detailed works estimates to be
attached with plans wherever necessary).
8 The amount of grant-in-aid applied for
(Should not exceed Rs. 3,000 /-)
9 Is the management prepared to accept
the terms and conditions laid down in
the enclosed form of agreement and to
execute such an agreement.
Signature of mine
owner’s
Scheme no. 4
BOND
BOND FOR PURCHASE OF A DISH ANTENNA FOR THE
RECREATION OF THE MINE WORKERS
This bond is made this the………………day of one thousand nine
hundred
and
ninety…………between
the………………………(Name of mine management its registered
office at…………………..(hereinafter referred to as the mine
management which expression shall unless excluded or by repugnant
to the subject or context to be deemed to be included their successors
in interest and assigns) of one part and president of India (hereinafter
referred to as “Government” which expressions assigns) of the other
part.
WHEREAS pursuant to the request of the mine managements the
government has agreed to provide a caloured / black and white TV set
coasting Rs…………/- (rupees….......only) to the said mine
management / society as per the provisions of prototyped scheme for
supply of TV sets to mine managements / beedi co-operative society
for recreation of their mines / beedi workers under iron ore,
manganese ore and chrome ore mine labour welfare act 1976
limestone and dolomite mines labour welfare fund act 1972, mica
mines labour welfare fund act 1946, beedi workers welfare fund act
1976. Up on furnishing a bond on the terms and conditions appearing
hereafter.
And whereas the said mine management / society has agreed to say
TV set.
NOW, THEREFORE THIS BOND WITNESS AND THE
PARTIES HERETO, hereby agree as follows
1 that the cost of TV set including all accessories shall not axed
Rs.10000/- (Rupees ten
thousand only)in case of colour TV and Rs 4000/-(Rupees four
thousand only)
2 That the TV set shall be purchased iron a government manufacturer
through a reputed
regular dealer and produce the cash memo to that effect or
reimbursement of the
admissible expenditure by the welfare commissioner-----------------------region
3 That the said mine management /society shall execute an agreement
in the prescribed
from of agreement
4 That the incidental expenses incurred in connection with operation
of the TV set will
have to borne by the said mine management / society
5 That suitable accommodation for installation of TV set shall be
provided by the said
mine management / society
6 That in case the TV set remain un-utilized for a reasonable period
and / or utilized other
that the purpose for which it is provided the welfare commissioner
shall have powers to
withdraw the TV set so provided to the mine management / society
7 That in case the like of life TV set is out lived its utility, the set
mine management /
society shall have no right to dispose of the TV set in any manner
they shall have to
return the TV set to the welfare commissioner, region and obtain
receipt in token there
of.
8 That the expenses incurred on repair up keep the TV set in good
working condition shall
be borne by the mine management / society.
9 That the TV set shall be installed at such a central place of mine /
beedi workers
population which are within their easy reach and can witness the TV
programmed at
large.
10 That the TV set shall be maintained in good condition and will be
used only for benefit
of mine / beedi workers
11 That any particulars, which the government or any person
authorized by it, may from
time to time require for the proper discharge of responsibility shall be
duty and
promptly supplied
12 That or necessary facilities shall be afforded for inspection by the
officers of
government or any person authorized by it.
13 That the TV set shall not be transferred or utilized by any other
than said mine /
management / society for the purpose it is meant for
In the event of violation of any of the aforesaid conditions by the said
mine
management / society of which the government shall be the sole
judge, the said mine
management / society shall be liable to pay the government amount
Rs. -----------together with the interest at the government rates for the time being in
force on demand
without a demur, for crediting the some to iron / chrome / manganese
ore mice mines /
limestone and dolomite mines / beedi workers labour welfare fund.
The bond is given for the performance of an act in which the public
are interested.
In witness where of the mine management / society have caused to
execute /
authorized their seal through their unauthorized representatives on the
day and year
first above written.
Sealed, signed and delivered this the ------------------day of the one
thousand nine
hundred and ------------------in the presence of.
WITNESS
1 Name
Father‟s name
Occupation
ResidenceResidence
Seal
2 Name Signature
Father‟s name
Occupation
Designation
AGREEMENT
AGREEMENT FOR PURCHASE OF A COLOURED / BLACK
& WHITE T.V. SET FOR THE RECREATION OF THE MINE
WORKERS
This agreement made this---------------day of----------------between the
president of India (herewith referred to as “the government”) of the
one part and the------------ (name of the mines management / beedi
co-operative society) (herein after referred to as the “employer”) of
the other part.
WHEREAS the iron ore. Manganese ore and chrome ore mines
labour welfare fund advisory committee / limestone and dolomite
mines labour welfare fund advisory committee / mica mines labour
welfare committee / beedi workers welfare fund advisory committee
for (state) has recommended the proposal for supply of coloured /
black and white TV set for the recreation of iron or manganese ore /
chrome ore / limestone and dolomite / mica mine workers / beedi
workers employed by the (employer) in accordance with the
provisions contained in iron ore mines and manganese ore mines /
chrome mines labour welfare fund act, 1976 / limestone and dolomite
mines labour welfare fund act, 1972 / mica mine labour welfare fund
act, 1946 / beedi workers welfare fund act, 1976.
AND WHEREAS in pursuance to the set recommendation, the
government has agreed to accept the proposal for the supply of
coloured / black and white TV set including all accessories, at cost
not exceeding Rs.---------------to the employer out of the iron ore /
manganese ore chrome ore labour welfare fund / limestone dolomite
mines labour welfare fund and the employer has agreed to accept the
same on the term and conditions appearing hereinafter.
NOW THIS INDENTURE WITNESSES THAT IN consideration the
aforesaid and in consideration of the terms and conditions to be
observed by the employer, the government has supplied one coloured
/ black and white TV set chassis-------------no.--------------------Make-----------------model---------------etc. (hereinafter referred to as
the said TV set) to the mines management / beedi co-operative society
and incurred Rs.-------------towards the cost of the said TV set.
2 The employer hereby undertakes that:(a)
The said TV set shall be used exclusively for the recreation
of the mine / beedi
workers but excluding the supervisory staff of the management /
beedi co-operative
society.
(b) On the body of the said TV set the words “supplied by the labour
welfare
organization “ shall be printed in English or local language commonly
understood
by the population of the region
(c)The said TV set shall not be disposed of encumbered, or utilized
for the propose
other than for the recreation of the mine / beedi workers.
(d) The employer shall at its expenses safeguard the said TV set,
maintain it in good
working order and shall bear full / cost
charges and expenditure on this proper
functioning un keep including repairs.
3 Any particulars, which the executive officer of the labour welfare
organization may
require from time to time for proper discharge of their responsibility
with regard to
the satisfactory and maintenance and proper use of the said TV set
shall be duty and
promptly supplied by the employer and for the verification, for which
necessary
facility for inspection shall be afforded.
4 It is further declared that in the event of violation of any of the
above conditions the
employers shall be liable the pay to the central government for
crediting to iron ore
manganese ore and chrome ore limestone and dolomite mica mines
labour welfare
fundbeedi workers welfare fund the entire amount incurred on the
purchase on the
said TV set along with interest on the cost of the TV as fixed by the
central
government
IN WITNESS HEREOF THE PARTIES caused their hands to set
through their
respective authorized representatives on the day and year first above
return.
Place:
Date: (signature)
In the presence of witnesses:(i)
(ii)
FORM OF THE APPLICATION FOR PROVIDING SUBSIDY
TO MANAGEMENT FOR PURCHASE OF DISH ANTENNA
(To be submitted in duplicate)
-------------------------------------1 Name of the mine management with full postal address
2 Total no. of workers employed in the mine
3 No. of houses provided to the workers
4 Total amount of cess paid for last 3 years
5 Location of the colony with the site
6 Is the place not covered by the existing TV network, name of the nearest
TV relay station and distance
7 Whether the management agrees to provide suitable facilities for
installation of dish antenna
8 Place of installation of dish antenna (please mark in the site plan with
place where antenna is to be installed)
9 Cost of this antenna and its capacity
10 Whether management is willing to incur the expense in connection with
installation of dish antenna
11 Whether the management is willing incur the expense in connection with
installation of dish antenna
12 Any other information relevant to the proposal
Date:
mine management with seal
Place:
Signature of the