ANNEXURE-A

	Swargadwar Seva Samiti, Puri Help For Harischandra Yojana, Application Submit in Puri Swargadwar (Chief Minister Relief Fund ANNEXURE-A ACCORDING)
Death Person Details

Male Female


Choose a District: Puri Angul Baudh Balangir Bargarh Balesore Bhadrak Cuttack Deogarh Dhenkanal Ganjam Gajapati Jharsuguda Jajpur Jagatsinghapur Khordha Keonjhar Kalahandi Kandhamal Koraput Kendrapara Malkangiri Mayurbhanj Nabarangpur Nuapada Nayagarh Rayagada Sambalpur Subarnapur Sundargarh Choose a State: Odisha

Choose a ID Proof: Ahar Card Voter ID Card PAN Card Driving Licenses Passport Attach ID proof of Decresed Person :

Choose any death declaration:
Hospital Death Declaration Corporator Declaration Sarapancha Declaration Asha Didi Declaration Attach Death Declaration :

Township Village Area






Applicant Details




Choose a District: Puri Angul Baudh Balangir Bargarh Balesore Bhadrak Cuttack Deogarh Dhenkanal Ganjam Gajapati Jharsuguda Jajpur Jagatsinghapur Khordha Keonjhar Kalahandi Kandhamal Koraput Kendrapara Malkangiri Mayurbhanj Nabarangpur Nuapada Nayagarh Rayagada Sambalpur Subarnapur Sundargarh Choose a State: Odisha Choose a ID Proof: Ahar Card Voter ID Card PAN Card Driving Licenses Passport Attach ID proof of Applicant :
Declaration:
We have no Four Wheeler in our Family.
In our Family No one Govt. Service Holder.
In our Family No one Govt. Pension Holder.
In our Family Total Land Not More than 5 Acers.
In our Family No one Income Tax Payer
I Read all Above Declaration.All Decaration are truth For my Family.
All Declaration Are true