ANNEXURE-A

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

Deceased Details

Deceased Name:

Deceased Age:

Male Female

Deceased Father/Husband Name:

Date:

Deceased DeathPlace:

Choose Deceased 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 Deceased State: Odisha

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/Sarapancha/WardmemberDeclaration MP/MLA/GOVT.OFFICIALDeathDeclaration Asha/AnganwadiWorkerDeathDeclaration

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: 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 Applicant State: Odisha

Choose Applicant ID Proof: AdharCard VoterIDCard PANCard DrivingLicenses Passport

Attach ID proof of Applicant:

Arrival Time:

Declaration:
We have no Four Wheeler in our Family.
In our Family No one each Govt. Employee.
In our Family No one each 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 true and correcte