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Annexure I

Certificate in respect of an orthopaedically disabled person regarding purchase of a passenger car for purpose of excise concession (Para 240 of Central Govt. Notification No.5/98-Central Excise dated 2.6.98)

1.	Name of the Person:	............................................................
2.	Father's/Husband's Name:	............................................................
3.	Residential Address :	............................................................
		............................................................
	Tel. No	(1)..........................(2)..........................
4.	Professional status:	............................................................
5.	Office Address:	............................................................
		............................................................
	Tel. No.:	(1)..........................(2)..........................
6.	Age:	............................................
7.	Sex:	............................................
8.	Marks of identification:	(1)........................................................
		(2)........................................................
9.	Annual Income:	............................................................
10.	Signature of the applicant:	............................................................
11.	Photograph - one copy (Full body clearly showing the Disability, postcard size duly Attested by the officer Issuing certificate)
12.	Medical examination :
	a) General state of health:	............................................................
	b) Vision including colour vision:	............................................................
	c) Hearing:	............................................................
	d) State of mental health:	............................................................
	e) Nature of OrthopedicImpairment & duration (Paralysis/Deformity/Loss of Limb/Any other Please Specify)	............................................................
	f) Cause of impairment:	............................................................
	g) Percentage of Orthopedic Impairment (in words & in figures)	............................................................
	h) Use of appliance if any :	............................................................
	i) Whether permanent in nature:	............................................................
13	It is certified that Shri/Smt/Ms.......................................................................... S/o-D/o-W/o Shri......................................... is fit/unfit to drive a passenger car fitted with Automatic transmission inspite of the above disability and cannot drive a Manual transmission car.
14	Case recommended/Not recommended:	...........................................................
15	Signature with legible rubber stamp of Signatory indicating his name designation & Official address (Rehabilitation Medicine Specialist/Ortho. Surgeon) of Govt. Hospital.
16	Countersignature of Civil Surgeon (Or equivalent rank) of a Govt. Hospital
OR
	Signatures of members of A designated medical board of govt. Hospital, issuing disability certificate



1........................................	2........................................	3........................................
(Signature)	(Signature)	(Signature)
(Stamp)	(Stamp)	(Stamp)

Annexure II

Indemnity Bond on a Non Judicial stamp paper of Rs.10 duly notarised by Notary Public. I,............................................................................ S/o-D/o-W/o Sh .........................................................., resident of................................................................................do hereby state:
1.	That I am interested in purchasing a Maruti Zen AX Easy Drive being currently manufactured by Maruti Udyog Limited Gurgaon through their authorised Dealers ............................
2.	I wish to purchase the above Maruti Zen at a concessional rate of excise duty as prescribed by the appropriate authority.
3.	I am a handicapped person with disability of .......................................................and therefore I have applied and obtained a Certificate from the ministry of Heavy industry and Public Enterprises for the purpose of concessional excise duty applicable in the condition No. 43 of notification No. 3/2001- Central Excise dated 1.3.2001.
4.	The existing normal excise duty (32%) on Zen vehicle is Rs...................................... and the concessional excise duty (16%) for physically handicapped persons is Rs...................... The difference in excise duty is Rs...................................... I wish to obtain the concessional excise duty amounting to Rs .......................................
5.	Consequently I ......................................................................., the executant of this document indemnify and undertake the following: In case the excise authorities disallow the above concession in excise duty, and show cause notice/demand is issued by them I will bear the differential amount of excise duty i.e. Rs ........................along with difference in central/local Sales tax along with any other levies.
.......................................... Name of the Customer

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