Transaction ID / Application No : Date of Application Done :

FAMILY MEMBER CERTIFICATE - APPLICATION FORM

Applicant Details
AADHAAR Card Number *: ______________________________

Applicant Name * : ______________________________

Father / Husband Name* : ______________________________

Gender (Male / Female) * : ______________________________ Date of Birth (dd/mm/yyyy) * : __________________

Caste (BC-A/BC-B/BC-C/BC-D/BC-E/OC/SC/ST) * : ___________ Religion * : ____________________________

Qualification * : ______________________________ Marital Status * : ____________________________

Mobile Number * : ______________________________ Email ID : ____________________________

Permanent Address
Door No & Street Name * : _______________________________________________________________________________

District * : _______________________________ Mandal * : ____________________________

Secretariat Name * : _______________________________ Pin Code * : ____________________________

Present Address
Door No & Street Name * : _______________________________________________________________________________

District * : _______________________________ Mandal * : ____________________________

Secretariat Name * : _______________________________ Pin Code * : ____________________________

Ration / Rice Card No : _______________________________

Deceased Details
Deceased First Name * : _______________________________ Deceased Last Name * : _______________________

Father / Husband Name *: _______________________________ Date of Death (dd/mm/yyyy) * : _______________

REASON FOR DEATH * :  Accident  Collapse of Buildings / Bridges  Drowning  Fire Accident
 Floods / Cyclones / Thunder Bolt  General Death  Ill Health  Missing  Murder  Suicide

OCCUPATION * :  Agriculture Labour  Building Construction Workers  Businessman  Central Govt Services  Coolie
 Farmer  Fishing  Handloom Worker  Other Occupations  Pensioner  Public Sector Undertakings
 Retired Employee  Rickshaw Puller/Auto/Taxi/Lorry Drivers/Cleaners  State Govt Services  Working in Factories

AADHAAR Number : ________________________________ Death Place *______________________________________________

AADHAAR Enrolment Number : Format (1234/12345/12345) : ________________________________________

Family Members Details

Relationship with
Name of the Family Member * Gender * Age * Marital Status * AADHAAR No. *
Deceased *

Applicant’s Signature

Documents List:
1. Application Form *
2. A Notarized Affidavit Containing Name, Age and Relationship with Deceased.*
3. Document (Ration card/ Voter ID Card/ Passport/ Passbook, Aadhaar cards, etc.) indicating the relationship of the
applicant with the deceased *
4. Death Certificate/FIR *