Harischandranew

ANNEXURE-A

Swargadwar Seva Samiti, Puri Application To Submit for Harischandra Yojana
(According To Chief Minister Relief Fund,ANNEXURE-A)

Deceased Details

Male Female

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Choose a death declaration:
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Township Village Area

Applicant Details Today Date:

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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 undertake that, All Above Declaration are truth and correcte