application for family members certificate

1. Family member
Applicant Details
AADHAAR Card Number *:________________
Applicant Name * :_______________________
Gender*:
Male
Female Date of Birth
Permanent Address:
Door No : ______________________________ Locality / Land Mark : __________________________
District*:__________________________
Village / Ward *:______________________________
Present Address:
Door No : ______________________________ Locality / Land Mark : __________________________
State*:______________________ District
Village / Ward *:____________________
Mobile * : _________________________
E-Mail: ________________________________ Remarks :_______________________________
Ration card NO :_______________________ Delivery Type
Deceased Details:
Deceased Name* : ______________________ father/Husband
Date of Death (DD/MM/YYYY)* : _____________________
Reason for Death* :
Accident
Floods / Cyclones / Thunder Bolt
Collapse of buildings/Bridges
Ill health
Occupation*:
State Government Services
Cooli
Agriculture Labor
Rickshaw Puller / Auto / Taxi / Lorry drivers/cleaners
construction workers
Working in factories
Retired Employee
Farmer
Business Man
AADHAAR Card Number: _______________________ Death place
Aadhaar Enrolment Number: Format
White to Pink Card
Family membership certificate -Application Form
:____________________________
_____________________ Relation Name* ________________
Female Date of Birth* (DD/MM/YYYY): _________________________________
______________________________ Locality / Land Mark : __________________________
________________ Mandal*:__________________________
:______________________________ Pin Code : ______________
______________________________ Locality / Land Mark : __________________________
____________________ District*:____________________ Mandal*:__________________________
:______________________________________________ Pin Code : __________________
_____________ Phone :_______________________________
Mail: ________________________________ Remarks :_______________________________
Ration card NO :_______________________ Delivery Type*:
Manual
Local post
: ______________________ father/Husband Name * :_____________________________
: _____________________
Floods / Cyclones / Thunder Bolt
Fire Accident
Drowning
Ill health
General Death
Suicide
Missing
Murder
State Government Services
Central Government Services
Public sector under takings
Rickshaw Puller / Auto / Taxi / Lorry drivers/cleaners
Building
Working in factories
Fishing
Other Occupations
Handloom Worker
Business Man
Pensioner
______________________ Death place *____________________________________
Number: Format (1234/12345/12345):______________________________
___________________________
(DD/MM/YYYY): _________________________________
______________________________ Locality / Land Mark : __________________________
______________________________ Locality / Land Mark : __________________________
:__________________________
Pin Code : __________________
Phone :_______________________________
Mail: ________________________________ Remarks :_______________________________
Non Local post
:_____________________________
Drowning
Murder
Public sector under takings
Building
Handloom Worker
____________________________________
______________________________

2. 2.Name of the Family
Member*
3.Age*
Documents List:
(NOTE: 1.Total size of Upload Document should not exceed 3 MB.2. All Upload Documents should be in PDF Format Only)
1. Application Form*
2. A notarized affidavit containing Name, Age and Relationship with deceased.
3. Document (Ration card/ Voter ID Card/ Passport/ Passbook, Aadhar cards, etc.) indicating the
relationship of the applicant with the deceased
4. Death Certificate/FIR*
4.Gender 5.Relationship with
Deceased*
Maritial status
(NOTE: 1.Total size of Upload Document should not exceed 3 MB.2. All Upload Documents should be in PDF Format Only)
containing Name, Age and Relationship with deceased.*
Document (Ration card/ Voter ID Card/ Passport/ Passbook, Aadhar cards, etc.) indicating the
relationship of the applicant with the deceased*
Applicant’s Signature
6.Aadhar
Number(UID) *
(NOTE: 1.Total size of Upload Document should not exceed 3 MB.2. All Upload Documents should be in PDF Format Only)
Document (Ration card/ Voter ID Card/ Passport/ Passbook, Aadhar cards, etc.) indicating the
Applicant’s Signature