This document is an application form for awarding a marriage incentive in Odisha, India for marriages between disabled and normal persons. The form collects information about the couple such as names, ages, addresses, education levels, disability status, marriage date and location. Supporting documents like disability certificates, marriage registration and joint photographs must be provided. A verification officer will check the documents and eligibility before a sanctioning authority approves and issues the marriage incentive award.

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Name andpresell address
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Nam; olbdd;, daughttu of
03. Age at the {me ofMaEia8e
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GOVERNMENT OF ODISHA
Dd.lk of PoEonr wtrh DLiatttid€s (Spo@)
4xtetu4e-1
WOMEN & CHIID DEVEI.OPMENT OEPARTMTNT
APPUCA'IOI{ FOflVI FOA AWAND Of MARTUAGE INCENTIVE FOR
MANX|AGE BETWEEN DlsqBED & NOAMAI PER5ON
IABII
[ro be nlbd h by the Coupte)
i 0 tue attheume ofmantace
w) nelision and Gste :
4r) Edu6tionalauanfi@dons :
i) Native Pla.e & AddrE!
)t Present place or living a.d Addre$
lD{'f
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4. tr. Det il ol oiher P.Eon (Spouse)
a) FullName r
b) sq (MarelFeftlle) .
c) Father'sName
e). Age.at the time ofmari.ge
, Sallslon and Gste :
s) Edu6tronal qualrl@uons :
h) Natlve Plae & Addre$
i) kesent Place of lMns and Addre$
rl
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v. cenlE6tes Enclose.l (Setf zttested 6pler:
{i) Disabilitycertificat€lssuedby :'YEslNO
oistrict MedicdlSoard as notified by rhe Governfient
(ii) MaEiaBe Reglstration ce.tlfiGte issued by tire @npet€nr
YE5/NO
R€8rst atun Authorlty of M5riages
lll. Date and pla.€ .t MardaEe
liliJfiifte Post Card size loint Photogiaph of the coupte
YEs/NO 3elf-atterted-

5. ir- ) Resldentlal @rdfi6te Bsued bv the lahsllda6 /
YES/No R*idendalProof ( )
(v) Prcof of joint a@u.t o, hcband & wife :
Bank autl,ori-atlon for e-tErder of the t$d
v, DedaEtion of HEband & Wife
. We ertirythat'the irforution fuhished above are rtue and coiicct.
we also cerrify th:t we h.ve not ctalned the Marn.ge ,n.entive Award
previou5ly. lf in atry @se, the itforEatio. slbmltted bv ut .E P@€d to be
wronP at any time, P€ underlEld we are liable for PGe@tion entailing of
Rs2oooo/-, impdsorment up to 2 y46 ard recovery ot Manlage lncentive
Aw d paid alorg wlth,2% lnleresttheleon.
slgnatuG ot other Peen {SD@e)
with Dlsabl,it,

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(to be filted h by rhe Ve.n@tion Oftrer
l#"#l::l;Eflii::#il,Hft ; ff 1.",.,,-,",.)
(il The coupte are haried and ltutng t gether j yes/No
(iii) DlsabllirycertiriGte : correcvln@ftct
.(iv) MartaEE BegistEtion Cerrfftate : Corrcrytncorect
(vlResidentlalcertifiete/prcofofAddrc$
: corect/,.coriect
(vi) A5 perenqu,ry the coupted have notah,t-"d
thehcenflveawardEartier : Cor.eci/h.orre,l
iJ;fi lffil{::J:.,T*end forranction or MariaeE rn.entive Awa rd
(ii) roint Photogaphs of rhe couple
a)
b)
d
(a) N.meofthe venflcdon ot cer
(a) oesignahion
Slgnature of th e ve riticat ion

7. PART - C
Fo be ffltEd tn bv the Sanctioning
authorlty)
aPdkation
fo' o1
scruti.lted
colledor and dnd6 Maistde
sot....,-'-___--.._-__-_ .nclorucrandvedfladonnePodo{
ueaine rumber ' -____-
ot '
."fth reter€nce
to the guld€rlnes
rhe verincanon
oincer -- --
-:^:;";",t ", "" ""r
ase hcent !e
and othe' @ldant lesano 14 _'-
dr,,.,-.----___'
A'xardtothe
spplontvide
No'"_" - " '-
n"leclllle same tor ttre totrowrne
re"ons"