Field Verification Proforma for Dr.

YSR Aarogyasri Health Card

Ration Card No:
Name of the Mandal:____________________ Name of the Village: ___________________________ FP shop No.:_______________________ House Hold Cluster No:_____________________

Family Members Details of 5 Step Validation

Death / Migration Due to Annual Family Income
Marriage / Not a member of

Agree / Disagree

Agree / Disagree

Agree / Disagree
Details of Details of 4 the Family / Birth /
Details of Municipal
family Wheeler Details of Permanent Migration
Age & Relation member if Govt. property
S.No Name Mobile No member (Personal Car) Land holding
Sex with HoF Employee/ details more
paying owned by family of the family
Pensioner than 3000 sq.ft
Income Tax member

Add
member

If applicant disagrees on the above, pl provide data as mentioned below.

FOUR WHEELER Please tick Family Income Details Please tick Family Land Holding Please tick ✓ Municipal Property details Please
✓ ✓ tick ✓

Second personal car was sold to other person but As per the Annual Salary certificate or IT Return, my Family's Applicant having property less than 3000
The extents of land details are not correct.
not updated in the Database. GROSS ANNUAL INCOME is less than Rs 5 Lakhs Sq.f. with assessment no._____________

Ancestral property . The Applicant is legal

Is your Land extent Less than 12 Ac Wet Land or Less than
Family never had any personal car I have never filed Income Tax Return heir and would get less than 3000 Sq.Ft. if
35 Ac Dry Land mutated / sub divided

I do not have more than one personal car. I have Is your Land extent Less than 35 Ac (both Wet & Dry)
only one.

second vehicle is not a personal car but it is TAXI. Do not own any land by applicant and family members

Pl write total No.of Personal Cars Owned PL Write Extent of Wet Land in Acr Pl write Area of Property in Sq.f

Pl write Extent of Dry Land in Acr

Pl write Total Extent of Land in Acr

 Supporting Document for the field verification after 5 Step Validation

Income Details Details of the Land Holding by the Family Property Tax Details
(Step-2) (Step-3) (Step-4)

Total Physical Remarks - As per As per Pattadar Physical Copy of Remarks - Physical Remarks -
Income of evidence of Eligible(E)/ Pattadar Passbook, Pattadar Passbook Eligible(E)/ Copy of Eligible(E)/
the Family Salary Ineligible(IE) Passbook, extend of Dry- Ineligible(IE) Property Ineligible(IE)
in Rs Certificate / extend of Land Taxes Paid
IT Return Wet-Land
Collected

డసస ససమర:

_________________ అన నన, _________________ గగమమనక చచదనవడన. పసన ఇచచన సమచరమ మతతమ సరయసనద. ఇచచన
సమచరమనక పరత బధధత వహచచచననన. తపపన తలత, పపభతతమ చటట రతధ ఏ చరధ తసకనన నన సదదమ. మరయ, కరర జర అనచతరమ న
ఆదయమలకన, భభమల కన, ఆసతల కన ఏదస న వధతధసమ ఉననచ వచటన గగమ సచవలయమనక తలయ చయటక సమఖమగ ఉననన.

పర:
సచతకమ :
తద :