Certificate by competent authority [as defined at rule 2(c)] For Indian near relative, other than spouse, cases

(In case of spousal donor, Form 6 w ill be applicable) [See rule 5(3)(c)] (Format for the decision of Competent Authority) This is to certify that as per application in Form-11 for transplantation o f_______________________(Name of Organ or Tissue) from living donor who is a near relative of the recipient under the Transplantation of Human Organs Act, 1994(42 of 1994), submitted on......................................by the donor and recipient, whose details and photographs are given below, along with their identifications and verifications documents, the case was considered after the personal interview of donor and recipient (if medically fit to be interviewed) by the competent authority in the meeting held on Details of Recipient Name.................................. Age..................................... Sex..................................... Father or Husband Name Adddress: Details of Donor Name:................................ Age................................... Sex................................... Father or Husband name Address: Hospital Reg. N o ............................... Hospital Reg. No Relation of donor with Recipient............................................................................... Recipient Donor (Photo of recipient and donor must be signed and stamped across the photo after affixing) Permission is granted, as to the best of knowledge of the members of the committee, donation is out of their being near relative and there is no financial transaction between recipient and donor and there is no pressure on / coercion of the donor. Permission is withheld pending submission of following documents....................................... Permission is not granted for the following reasons (Signature and stamp of competent authority) Date and place...............................................