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S.No.
Name
Age
Select Age
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100
Gender
Select Gender
Male
Female
Marital Status
Select an option
Married
Unmarried
Relation to Head of the Family
Social Condition
Orphan
Widow
Deserted by Husband
Disabled
Social Condition
Orphan
Disabled
Type of Disability
Medical Certificate
If applicant is Physically Handicapped please mention whether medical Certificate is there or not
Select an option
Yes
No
Husband's Death Certificate
If applicant is a Widow please mention whether Husband's Death Certificate is there or not
Select an option
Yes
No
Is Receiving Widow Pension
Select an option
Yes
No
Is Receiving Disabled Pension
Select an option
Yes
No
Is Receiving Old Age Pension
Select an option
Yes
No
Level of Education
Select an option
Schooling
Diploma
Intermediate (PUC/10+2)
Undergraduate
Postgraduate
Doctorate (PhD etc...)
Illiterate
Whether Attending School
Select an option
Yes
No
Whether Attending Madrasah
Select an option
Yes
No
Employment Status
Select an option
Employed
Unemployed
Professional Occupation
Monthly Income
Health Condition
Please mention whether the applicant is suffering from any Chronic disease
Heart Disease
Kidney Disease
Cancer
Sugar
Asthma
TB, etc
Government Health Card
Select an option
Yes
No
Is Bank Account Opened
Please mention whether Bank is opened or not
Select an option
Yes
No
Bank Details
Please mention Bank Name & Branch
Electricity Connection
Please mention whether applicant has Electricity Connection or not
Select an option
Yes
No
Average Monthly Bill
Water Connection
Please mention whether applicant has Water Tap Connection or not
Select an option
Yes
No
Toilet
Please mention whether applicant has a Toilet or not
Select an option
Yes
No
Aadhaar Card
Mention Whether Aadhaar Card is issued or not
Select an option
Yes
No
Aadhaar Number
Enter your Aadhaar number
Voter ID
Mention Whether Voter ID is issued or not
Select an option
Yes
No
Voter ID number
Enter your Voter ID number
PAN Card
Mention Whether PAN card is issued or not
Yes
No
PAN Card number
Enter your PAN Card number
Passport
Mention Whether Passport is issued or not
Yes
No
Passport Number
Enter your Passport number
Driving License
Mention Whether Driving License is issued or not
Yes
No
Driving License Number
Enter your Driving License number
Is BPL Ration Card issued
Please mention whether Ration Card is issued or not
Select an option
Yes
No
BPL Ration Card Number
Enter your BPL Ration Card number
Health Card
Mention which Health Card you have
Labour Card
Please mention whether Labour Card is issued or not
Yes
No
Labour Card Number
Enter your Labour Card number
Gruha Lakshmi Scheme
Please mention whether applied Gruha Lakshmi Scheme or not
Yes
No
Widow/Old age/Handicap Pension
Mention whether receiving Widow/Old age/Handicap Pension or not
Yes
No
Any Scholarships applied
Mention whether any Scholarship is applied
Yes
No
Income Caste Certificate
Mention whether Income/Caste Certificate is Issued or not
Yes
No
Income Caste Certificate Number
Enter the Income Caste Certificate number
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