General

ANNEXURE-A

Swargadwar Seva Samiti, Puri
Apply For General Yojana

Deceased Details
Deceased Name:
Deceased Age:
Male Female
Deceased Father/Husband Name:
Date:
Deceased DeathPlace
Choose Deceased District:
Choose a State:
Deceased DeathCause
Deceased Job(Profession of the Deceased)
Choose Deceased ID Proof:
Attach ID proof of Deceased Person :
Choose a death declaration:
Attach Death Declaration:

Township Village Area
Deceased Village/Street:
Deceased Ward No:
Deceased Post Office:
Deceased Police Station:
Deceased Panchayat:
Deceased Block/Municipality/Nac:
Applicant Details
Date of Application:
Applicant name:
Applicant Relation:
Applicant Mobile No:
Applicant Address:
Choose Applicant District:
Choose a State:
Choose Applicant ID Proof:
Attach ID proof of Applicant:

Arrival Time:

I undertake that, All Above Declaration are true and correcte

Swargadwar Seva Samiti, Puri

Deceased Details

Deceased Name:

Deceased Age:

Deceased Father/Husband Name:

Date:

Deceased DeathPlace

Choose Deceased District:

Deceased DeathCause

Deceased Job(Profession of the Deceased)

Choose Deceased ID Proof: AdharCard VoterIDCard PANCard DrivingLicenses Passport

Attach ID proof of Deceased Person :

Choose a death declaration: Hospital/DoctorDeathDeclaration Corporator/Sarpanch/WardmemberDeclaration MP/MLA/Govt.OfficialDeathDeclaration Asha/AnganwadiWorkerDeathDeclaration

Attach Death Declaration:

Deceased Village/Street:

Deceased Ward No:

Deceased Post Office:

Deceased Police Station:

Deceased Panchayat:

Deceased Block/Municipality/Nac:

Applicant Details

Date of Application:

Applicant name:

Applicant Relation:

Applicant Mobile No:

Applicant Address:

Choose Applicant ID Proof: AdharCard VoterIDCard PANCard DrivingLicenses Passport

Attach ID proof of Applicant: Arrival Time:

Choose Deceased ID Proof:

Choose a death declaration:

Choose Applicant ID Proof:

Attach ID proof of Applicant:

Arrival Time: