TPS - at Hwaroctdsw Ce 0G HSE SeveSs0 3 YSR Vahanamitra Field Verification Form SECRETARIAT NAME Name Of the Applicant: Name of the Father/husband- Rice Card Number- Driving license Number Gender- - Mobile Number- Volunteer Name- S.No Category As Per System Validation Details at Family Income for a month i .permonth | Rs... Per month > Dry Land holding of family "Acres . nites _| 3 Wet Land holding of Family su Actes 1 Acres | Four-wheeler in Family (Yes/No) Yes/No Yes/No 5 _| Govt. Employee in Family (Yes/No ERIN Yes/No 3 Electricity consumption Units Units 7 | Property in Municipal/Plinth area ins qFt ins qrt 7 Income Tax payee in family Yesjtio Yes/No Remarks Eligible/Inetigibie: | Solemnity state that the above -mentioned particulars are true to the best of my knowledge and belief and that it conceals nothing and that no part of it is false. In case if found future that the declaration given above is false, | am liable for prosecution. Sign of the Welfare &Education Assistant