ANNEXURE-A

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

Applicant Details

Male Female


Choose Decreased 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 Decreased State: Odisha

Choose Decreased ID Proof: AdharCard VoterIDCard PANCard DrivingLicenses Passport Attach ID proof of Decresed Person :

Choose a death declaration:
HospitalDeathDeclaration CorporatorDeclaration SarapanchaDeathDeclaration AshaDidiDeathDeclaration Attach Death Declaration :

Township Village Area






Applicant Details Today Date:




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 :
Reach Time:
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