11/4/23, 5:39 PM SSEPD::Social Security & Empowerment of Persons With Disabilities Department

Madhu Babu Pension Yojana Application Form

Pension Type : Old Age Pension Name : Purushottam Lal Sharma

Father's/Spouse Rameswar Lal

Name : DOB : 01-07-1961
Sharma

AGE : 62 Aadhar No : 698233589976

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Aadhar Scan Copy : Gender : Male
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Additional
Document
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Mobile No : 9583675051 District : CUTTACK

Sub-division : CUTTACK Address Type : ULB
Municipal
ULB Type : Municipality : Cuttack M
Corporation
City/Town : Cuttack Ward No : WARD-13
Ganesh Mandir
House No/Plot No : PIN : 753002
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11/4/23, 5:39 PM SSEPD::Social Security & Empowerment of Persons With Disabilities Department

The
parental/family Has not been
income of the convicted of any
applicant is not : Yes criminal offence : Yes
more than involving moral
Rs.60,000/-per turpitude.
annum.
Is a permanent
resident/domicile Application
of Odisha since 20
: Yes Number
: SSEPD/BNFAPP/MBPY/11/04/2023/935743
years.

Bank Account Details

Bank Account Type : Joint Bank Account Account Holder Name : Purusottam Lal Sharma
Additional Account Holder Name : Santosh Sharma Upload Passbook Front Page : View Passbook
Account Number : 33394533150 IFSC Code : SBIN0000059
Bank Name : STATE BANK OF INDIA Branch Name : CUTTACK
Declaration

I Mr/Mrs Purushottam Lal Sharma truely declare that:

The parental/family income of the applicant is not more than Rs.60,000/-per annum.

Has not been convicted of any criminal offence involving moral turpitude.

Is a permanent resident/domicile of Odisha since 20 years.

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I
undertake to inform you of any changes therein, immediately.In case any of the above information is found to be false or untrue
or misleading or misrepresenting, I am aware that I may be held liable for it and that my pension will be terminated.

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