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:
Choose Deceased 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 Applicant State:
Choose Applicant ID Proof:
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

Harischandra Yojana

Deceased Name

Deceased Age

Gender

Deceased Father/Husband Name

Date

Time

Deceased Death Place

Choose Deceased District

Choose Deceased State

Deceased Death Cause

Deceased Job (Profession of the Deceased)

Choose Deceased ID Proof

Attach ID Proof of Deceased Person

Maximum file size: 516MB

Choose a Death Declaration

Attach Death Declaration

Maximum file size: 516MB

Area

Deceased Village/Street

Deceased Ward No

Deceased Post Office

Deceased Police Station

Deceased Panchayat

Deceased Block/Municipality/Nac

Applicant Details

Date of Application

Time of Application

Applicant Name

Applicant Relation

Applicant Mobile No

Applicant Address

Choose Applicant District

Choose Applicant State

Choose Applicant ID Proof

Attach ID Proof of Applicant

Maximum file size: 516MB

Arrival Date

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 correct

If you are human, leave this field blank.

Swargadwar Seva Samiti, Puri

Apply for Harischandra Yojana

(According To Chief Minister Relief Fund,ANNEXURE-A)

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

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 :

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 State: Odisha

Choose Applicant ID Proof: AdharCard VoterIDCard PANCard DrivingLicenses Passport

Attach ID proof of Applicant:

Arrival Time:

Applicant Details

Choose Deceased District:

Choose Deceased State:

Choose Deceased ID Proof:

Choose a death declaration:

Choose Applicant State:

Choose Applicant ID Proof: