ANNEXURE-A

Swargadwar Seva Samiti, Puri
Apply For General Yojana

Deceased Details
Deceased Name:
Deceased Age:
Male Female
Deceased Father/Husband Name:
Date:
Deceased DeathPlace
Choose Deceased District:
Choose a State:
Deceased DeathCause
Deceased Job(Profession of the Deceased)
Choose Deceased ID Proof:
Attach ID proof of Deceased Person :

Choose a death declaration:

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:
Choose a State:
Choose Applicant ID Proof:
Attach ID proof of Applicant:

Arrival Time:

I undertake that, All Above Declaration are true and correcte

Swargadwar Seva Samiti, Puri

ANNEXURE-A

Deceased Details

Deceased Name:

Deceased Age:

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

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/Sarpanch/WardmemberDeclaration MP/MLA/Govt.OfficialDeathDeclaration Asha/AnganwadiWorkerDeathDeclaration

Attach Death Declaration:

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 ID Proof: AdharCard VoterIDCard PANCard DrivingLicenses Passport

Attach ID proof of Applicant: Arrival Time:

Choose Deceased District:

Choose Deceased ID Proof:

Choose a death declaration:

Choose Applicant ID Proof:

Attach ID proof of Applicant:

Arrival Time: