REVENUE DEPARTMENT, GOVT.

OF NCT OF DELHI
APPLICATION FORM – SURVIVING MEMBER CERTIFICATE
APPLICANT DETAILS

1. e-DistrictRegistration Number :
(For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number)
OR
2. UID (AADHAAR) No :
3. Name of Applicant : ___________________________________________ Applicant color
4. Name of Father : ___________________________________________ Passport Size
5. Name of Mother : ___________________________________________ Photograph
6. Name of Spouse : ___________________________________________ Size – 5 x 4.5 (Cm.)
Or
7. Gender : Male Female Other 2 x 1.75 (Inch)
8. Date of Birth :
DD MM YYYY
9. Mobile No: Email address: _____________@__________

10. Present Address :

House Name/No : ______________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : ______________________
State : ______________________ Country : _______________________
PIN Code :
11. Whether the Present and Permanent Address is same : Yes No
12. if No, Permanent Address :
House Name/No : ______________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : ______________________
State : ______________________ Country : _______________________
PIN Code :
13. Purpose of Certificate : ___________________________________

14. Relationship of the Applicant with Deceased : __________________________________

Details Of Deceased
15. Name of Deceased : ___________________________________________ Deceased Person
16. Father’s / Husband’s Name : ___________________________________________ colour Passport
17. Mother’s Name : ___________________________________________ Size Photograph
18. Gender : Male Female Other Size – 5 x 4.5 (Cm.)
Or
2 x 1.75 (Inch)

19. Death Certificate No. :___________________ (Attach death certificate along with Application)

Certificate Issue Date : DD MM YYYY Date of Death : DD MM YYYY

APPLICATION FORM – SURVIVING MEMBER CERTIFICATE

 20. Details of Surviving Family Members
S.No Name Age (In Years) Relation with Deceased Photo

Identity Proof (Please tick one, provide the document No. and attach the same) Colour Passport Size
Aadhaar Card Passport Driving License Photograph
1.
PAN Card Ration Card with Photograph Voter ID Card Size – 5 x 4.5 (Cm.)
Any Govt. recognized Document Or
Document Number : 2 x 1.75 (Inch

Identity Proof (Please tick one, provide the document No. and attach the same) Colour Passport Size
Aadhaar Card Passport Driving License Photograph
2.
PAN Card Ration Card with Photograph Voter ID Card Size – 5 x 4.5 (Cm.)
Any Govt. recognized Document Or
Document Number : 2 x 1.75 (Inch

Identity Proof (Please tick one, provide the document No. and attach the same) Colour Passport Size
Aadhaar Card Passport Driving License Photograph
3.
PAN Card Ration Card with Photograph Voter ID Card Size – 5 x 4.5 (Cm.)
Any Govt. recognized Document Or
Document Number : 2 x 1.75 (Inch

Identity Proof (Please tick one, provide the document No. and attach the same) Colour Passport Size
Aadhaar Card Passport Driving License Photograph
4.
PAN Card Ration Card with Photograph Voter ID Card Size – 5 x 4.5 (Cm.)
Any Govt. recognized Document Or
Document Number : 2 x 1.75 (Inch
If Surviving members are more than 4, Please attach list of surviving members with this application form in above specified format.
21. Identity Proof of Applicant (Please tick one, provide the document No. and attach the same )
Aadhaar Card PAN Card Ration Card with Photograph
Voter ID Card Passport Driving License
Any Govt. recognized document Document No :
22. Present Address Proof of Applicant (Please tick one, provide the document No. and attach the same )
AADHAR Card Voter ID Card Driving License
Passport Ration Card . Electricity Bill DISCOM Name___________
Water Bill Utility Name _____________________ . Gas Bill Comp Name _____________
Telephone Bill Company name_______________ Any Govt. recognized document
Rent Agreement (Registered) Bank Passbook Document No :
23. Permanent Address Proof of Applicant (Please tick one, provide the document No. and attach the same )
AADHAR Card Voter ID Card Driving License
Passport Ration Card . Electricity Bill DISCOM Name___________
Water Bill Utility Name _____________________ . Gas Bill Comp Name _____________
Telephone Bill Company name_______________ Any other Govt. recognized document
Rent Agreement (Registered) Bank Passbook Document No :

Date: DD MM 20YY
Applicant Signature :
Place: ______________________

APPLICATION FORM – SURVIVING MEMBER CERTIFICATE

 24. Self-Declaration

I ________________________________________S/o/D/o Sh._______________________________
aged _______________R/o____________________________________________________________
Verify as Under:
I. That the above contents are correct to the best of my knowledge and belief and nothing has been concealed
therein.
I further affirm that-
II. I am aware that in case the information furnished above is found to be incorrect, I shall be liable for prosecution
under section 177 & 191 of the Indian Penal Code, which stipulates as under:-
177. Furnishing False Information- whoever, being legally bound to furnish information on any subject to any
public servant, as such, furnishes, as true, information on the subject which he knows or has a reason to believe
to be false, shall be punished with simple imprisonment for a term which may extend to six months, or fine which
may extend to one thousand rupees, or with both;

Or, if the information which he is legally bound to give respects the commission of an offence, or is required for
the purpose of preventing the commission of an offence, or in order to the apprehension of an offender, with
imprisonment of either description for a term which may extend to two years, or with fine, or with both.

191. Giving false evidence- Whoever being legally bound by an oath or by an express provision of law to state
the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false,
and which he either knows or believes to be false or does not believe to be true, is said to give false evidence.
III. Providing any false evidance shall be punishable under section 193 of IPC, 1860 which provides imprisonment
for a term upto three years and fine.

Date: DD MM 20YY
Signature of Beneficiary :
Place: ______________________ (Parents Signature in case of Minor)

APPLICATION FORM – SURVIVING MEMBER CERTIFICATE