YSR Pension Kanuka Field Verification Form

SECRETARIAT NAME SECRETARIAT CODE

Name Of the Applicant Aadhaar Number -

Name of the Father/husband Cast Sub Cast
Rice Card Number Income Certificate No
Income Certificate No ------------------------------.Education Qualification…………………………
Gender- Mobile Number Habitation
Type Of the Pension Age Date of Birth - -
Volunteer Name Volunteer ID
Volunteer Mobile:-------------------------------------------.

S. No Category As Per System Validation Details

1 Family Income for a month Rs ....................... per month Rs ................. Per month
2 Dry Land holding of family ………………..……………. Acres ……………..……..………Acres
3 Wet Land holding of Family ………………..……………. Acres …………….………..…… Acres
4 Four-wheeler in Family (Yes/No) Yes/No Yes/No
5 Govt. Employee in Family (Yes/No Yes/No Yes/No
Electricity consumption
6 ..………………..……………. Units ……....…………………. Units
Property in Municipal/Plinth area
7 ……………………………. In S q Ft ………….……………. In S q Ft

8 Income Tax payee in family Yes/No Yes/No

9 Any Other Pension in the family Yes/No Yes/No

Remarks
Eligible/Ineligible:

I 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, I am liable for prosecution.

Sign of the Ward Welfare& Development Secretary