DISTRICT ADMINISTRATION, GURUGRAM

A. Head of Family(HOF) Details Family ID (If available)………………………………………………

1. HOF Aadhaar No. …………………272844966754……………………………………………………………( 12 digits)
2. Name (as in Aadhaar) …………SATISH KUMAR……………………………………………………………..(Capital Letters)
3. Relation with HOF : FATHER 4.Sex: Male 5. Date of Birth:20/07/1978.
6. Father’s Name: SH. SADARAM ………………………………………………………………………………………………………….
7. Mother’s Name : …SMT RAMKALI…………………………………………………………………………………………………….
8. *** Marital Status: …MARRIED……………………… 9. Spouse Name : …REKHA……………..………………………..
10. Caste Cate: OBC 11. Divyang : NO 12.BPL : NO 13. Govt. Employee:NO
14. Birth Place: Haryana
If HYR Distt. ………GURUGRAM………………… Block/MC: ………………………… Village/Ward: …
SHIKOHPUR……………………….
15. Residing in HRY Since: …BY BIRTH…………….. 16. Qualification: …12TH
PASS…………………………………………………..
17. ** Occupation: …………………FARMER……………………. 18. Annual Income : ……4,00,000/-
………………………………..
19. Residence Add: ………………HOUSE NO.-174
SECTOR-1, IMT MANESAR…………………………………………………………………………………………………
20. Mobile No: ………9971960018………………………
21. Email ID: satish20071978@gmail.com…………………………………………………………………..
22. PAN No: …
BCRPK5013K…………………………………………………………………………………………………………………………..

B. Please fill below information for all Family Members.

Member-1 Details.
1. Aadhaar No.: …………………965588654822………………………………………………………………………………. (12
digits)
2. Name (as in Aadhaar) …REKHA……………………………………………………………..…………..(Capital Letters)
3. *Relation with HOF : …WIFE……… 4.Sex:Female 5. Date of Birth: 1/1/1976
6. Father’s Name: ………………………………………………………………………………………………………….
7. Mother’s Name : ……………………………………………………………………………………………………….
8. *** Marital Status: …MARRIED……………………… 9. Spouse Name : ……………SATISH KUMAR…..
………………………..
10. Divyang : N0 11. Govt. Employee: N0
12. Birth Place: Haryana
If HYR Distt. …GURUGRAM……………………… Block/MC: ………………………… Village/Ward: … HOUSE NO.-174
 SECTOR-1, IMT MANESAR ……………………….
13. Residing in HRY Since: BY BIRTH……………….. 14. Qualification: ………
12TH……………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: …………………………………………………………………..
19. PAN No: …………
CHUPR5400G…………………………………………………………………………………………………………………..
*Relationship with Head of Family(HOF): Wife/Son/Daughter/Father/Mother/Brother/Sister/etc.
**Occupation:Farmer/Labour/State Govt.emp/Central or PSU emp/Private Industry/Housewife/Student/Infant/Business/Construction worker/Unorganised
Labour/Umemployed etc(Head of Family relationship will be Self)
*** Marital Status: Marries/Unmarried/Widow/Divorced Website: http://meraparivar.haryana.gov.in
PAGE NO.2

Member-2 Details.
1. Aadhaar No.: …………………347266433722………………………………………………………………………………. (12
digits)
2. Name (as in Aadhaar) …………JATIN………………………………………………………..………..(Capital Letters)
3. *Relation with HOF : …SON………. 4.Sex: Male 5. Date of Birth: 31/01/2003
6. Father’s Name: …………SATISH KUMAR……………………………………………………………………………………………….
7. Mother’s Name : …REKHA…………………………………………………………………………………………………….
8. *** Marital Status………UNMARRIED……………… 9. Spouse Name : ………………..………………………..
10. Divyang :NO 11.. Govt. Employee: NO
12. Birth Place: Haryana/ Outside Haryana (if Haryana give below details)
If HYR Distt. …GURUGRAM……………………… Block/MC: ………………………… Village/Ward: …… HOUSE NO.-
174
SECTOR-1, IMT MANESAR …………………….
13. Residing in HRY Since: ……BY BIRTH. 14. Qualification: …STUDENT…………………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: ……
Jatinrao00005@gmail.com……………………………………………………………..
19. PAN No: ……………………………………………………………………………………………………………………………..

Member-3 Details.
1. Aadhaar No.: …………………………………………………………………………………………………. (12 digits)
2. Name (as in Aadhaar) ……………………………………………………………………………..(Capital Letters)
3. *Relation with HOF : …………. 4.Sex: Male/Female/Others 5. Date of Birth: ……/……/..…….
6. Father’s Name: ………………………………………………………………………………………………………….
7. Mother’s Name : ……………………………………………………………………………………………………….
8. *** Marital Status: ………………………… 9. Spouse Name : ………………..………………………..
10. Divyang : Y/N 11.. Govt. Employee: Y/N
12. Birth Place: Haryana/ Outside Haryana (if Haryana give below details)
If HYR Distt. ………………………… Block/MC: ………………………… Village/Ward: ………………………….
13. Residing in HRY Since: ……………….. 14. Qualification: ……………………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: …………………………………………………………………..
19. PAN No: ……………………………………………………………………………………………………………………………..

*Relationship with Head of Family(HOF): Wife/Son/Daughter/Father/Mother/Brother/Sister/etc.

**Occupation:Farmer/Labour/State Govt.emp/Central or PSU emp/Private Industry/Housewife/Student/Infant/Business/Construction worker/Unorganised
Labour/Umemployed etc(Head of Family relationship will be Self)
*** Marital Status: Marries/Unmarried/Widow/Divorced
Municipal Corporation, Gurugram Website: http://meraparivar.haryana.gov.in NIC HARYANA

Member-4 Details.
4. Aadhaar No.: …………………………………………………………………………………………………. (12 digits)
5. Name (as in Aadhaar) ……………………………………………………………………………..(Capital Letters)
6. *Relation with HOF : …………. 4.Sex: Male/Female/Others 5. Date of Birth: ……/……/..…….
6. Father’s Name: ………………………………………………………………………………………………………….
7. Mother’s Name : ……………………………………………………………………………………………………….
8. *** Marital Status: ………………………… 9. Spouse Name : ………………..………………………..
10. Divyang : Y/N 11.. Govt. Employee: Y/N
12. Birth Place: Haryana/ Outside Haryana (if Haryana give below details)
If HYR Distt. ………………………… Block/MC: ………………………… Village/Ward: ………………………….
13. Residing in HRY Since: ……………….. 14. Qualification: ……………………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: …………………………………………………………………..
19. PAN No: ……………………………………………………………………………………………………………………………..

Member-5 Details.
7. Aadhaar No.: …………………………………………………………………………………………………. (12 digits)
8. Name (as in Aadhaar) ……………………………………………………………………………..(Capital Letters)
9. *Relation with HOF : …………. 4.Sex: Male/Female/Others 5. Date of Birth: ……/……/..…….
6. Father’s Name: ………………………………………………………………………………………………………….
7. Mother’s Name : ……………………………………………………………………………………………………….
8. *** Marital Status: ………………………… 9. Spouse Name : ………………..………………………..
10. Divyang : Y/N 11.. Govt. Employee: Y/N
12. Birth Place: Haryana/ Outside Haryana (if Haryana give below details)
If HYR Distt. ………………………… Block/MC: ………………………… Village/Ward: ………………………….
13. Residing in HRY Since: ……………….. 14. Qualification: ……………………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: …………………………………………………………………..
19. PAN No: ……………………………………………………………………………………………………………………………..
*Relationship with Head of Family(HOF): Wife/Son/Daughter/Father/Mother/Brother/Sister/etc.
**Occupation:Farmer/Labour/State Govt.emp/Central or PSU emp/Private Industry/Housewife/Student/Infant/Business/Construction worker/Unorganised
Labour/Umemployed etc(Head of Family relationship will be Self)
*** Marital Status: Marries/Unmarried/Widow/Divorced
Municipal Corporation, Gurugram Website: http://meraparivar.haryana.gov.in NIC HARYANA

Member-6 Details.
10. Aadhaar No.: …………………………………………………………………………………………………. (12 digits)
11. Name (as in Aadhaar) ……………………………………………………………………………..(Capital Letters)
12. *Relation with HOF : …………. 4.Sex: Male/Female/Others 5. Date of Birth: ……/……/..…….
6. Father’s Name: ………………………………………………………………………………………………………….
7. Mother’s Name : ……………………………………………………………………………………………………….
8. *** Marital Status: ………………………… 9. Spouse Name : ………………..………………………..
10. Divyang : Y/N 11.. Govt. Employee: Y/N
12. Birth Place: Haryana/ Outside Haryana (if Haryana give below details)
If HYR Distt. ………………………… Block/MC: ………………………… Village/Ward: ………………………….
13. Residing in HRY Since: ……………….. 14. Qualification: ……………………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: …………………………………………………………………..
19. PAN No: ……………………………………………………………………………………………………………………………..
Member-7 Details.
13. Aadhaar No.: …………………………………………………………………………………………………. (12 digits)
14. Name (as in Aadhaar) ……………………………………………………………………………..(Capital Letters)
15. *Relation with HOF : …………. 4.Sex: Male/Female/Others 5. Date of Birth: ……/……/..…….
6. Father’s Name: ………………………………………………………………………………………………………….
7. Mother’s Name : ……………………………………………………………………………………………………….
8. *** Marital Status: ………………………… 9. Spouse Name : ………………..………………………..
10. Divyang : Y/N 11.. Govt. Employee: Y/N
12. Birth Place: Haryana/ Outside Haryana (if Haryana give below details)
If HYR Distt. ………………………… Block/MC: ………………………… Village/Ward: ………………………….
13. Residing in HRY Since: ……………….. 14. Qualification: ……………………………………………………..
15. ** Occupation: ………………………………………. 16. Annual Income : ……………………………………..
17. Mobile No: ……………………………… 18. Email ID: …………………………………………………………………..
19. PAN No: ……………………………………………………………………………………………………………………………..
(Use additional sheet if more members are in family, name spellings should be same as in aadhaar card,
attach photo if possible)
*Relationship with Head of Family(HOF): Wife/Son/Daughter/Father/Mother/Brother/Sister/etc.
**Occupation:Farmer/Labour/State Govt.emp/Central or PSU emp/Private Industry/Housewife/Student/Infant/Business/Construction worker/Unorganised
Labour/Umemployed etc(Head of Family relationship will be Self)
*** Marital Status: Marries/Unmarried/Widow/Divorced
Municipal Corporation, Gurugram Website: http://meraparivar.haryana.gov.in NIC HARYANA