F O R M

APPLICATION FORM FOR FAMILY BENEFIT SCHEME.

1. (To be filled up by the applicant).

District:-                                                           Municipality/Town Committee

                                                                        Gaon Panchayat.

Village/ Panchayat/ Ward/ House No.

(as applicable).

2         Shri/Smti:-

3         Name of Father/ Husband:-

4         Categories:-                                                      SC/ST (H) (P)/Woman/Landless/

Handicapped/General.

5         Full Address     :-

6         Name of deceased:-

7         Certificate from the local panchayat to the effect that the deceased was the principal bread earner and has living below the poverty line.

8         Relationship with the deceased:-

9         date of death of the deceased:-

10     Whether Death certificate is enclosed:-

11     Declaration:- I solemnly affirm that:-

a.       I do not have any family income of Rs.11,000/- per annum or more.

b.       I am a resident of …………………………………....(District/State)

c.       I have not applied previously for grant of relief under the National       

Family Benefit Scheme.

d.       I declare that the information furnished in this application is true and   

Correct to the best of my knowledge and belief.

                                                      Signature or Thumb impression

of the applicant.

Place:-

            Date:-

                        (To be filled up by the enquiry authority)

                        Results of preliminary enquiry by the village/panchayat

                        Municipality Board/ Town Committee.

1. Name of the applicant:-
2. Income Destitution:-
3. Category:-
4. Whether the applying for the first time, if not, the decision on the last application.
5. Whether the applicant is now the head of the household.
6. Recommendation:-

Signature of verifying person

Gaon Panchayat/ President/ Chairman

Town Committee/ Chairman Municipality Board.

Date:-                                                               Full Address:-

Note:- This application should be sent with full particulars to the Deputy Commissioner of the concerned district.

            Remarks of the Deputy Commissioner.

            Accepted/Rejected