District Administration, Gurugram

A. Head of family (HOF) Details Family ID (if available) _____________________

_________________________________
1.HOF Aadhaar No. _______________
________________________________________ (12 digit)
2. Name (as in aadhaar)________________________
___________________________________________(Capital letters)
3.Relation with HOF : SELF 4. Sex : Male/Female/Other
Male/Female/Other5. Date of Birth : ___________________
____________
6. Father Name:: _______________________
____________________________________________________
7. Mother Name: ________________________________
________________________________________
8.***Marital Status :______________
:_____________________9. Spouse Name: _____________________________
__________________
10.Caste Cate : Gen/SC/BC-A, BC-B /Oth 11.Divyang : Y/N 12.BPL : Y/N13.Govt.
Govt. Employee : Yes/No
14.Birth Place:Haryana
Haryana / Outside Haryana (if Haryana then give below details)
if HYR Distt. ___________________Block/MC
________Block/MC : ___
_____________________Village/Ward :____________________
__________________________

15.Residing
Residing in HRY Since : ___________ 16.Qualification: ______________________________
______________________
17**.Occupation : ___________________________
__________________________
18.Annual
Annual Income : _______________
_____________________________________
19.Residence
Residence Add. : ______________________________________
_____________________________________________________________________
____________________
20.Mobile
Mobile No.: _______________________
____________________________21.Email : _________________
_______________________________
22.PAN
.PAN No. : _______________________
__________________________________________
B. Please fill below information for all family members.
Member-1 Details
1.Aadhaar No. ___________________
_____________________________________ (12 digit)

2. Name (as in aadhaar)________________________

___________________________________________ (Capital letters)
3*.Relation with HOF:______________________
______________________ 4. Sex: Male/Female/Other 5. Date of Birth : _________
______

6. Father Name: _________________

__________________________________________

7. Mother Name: __________________________

____________________________

8***. Marital Status :__________________

____________ 9. Spouse Name: ___________
____________________

10.Divyang : Yes/No11.Govt.
.Govt. Employee : Yes/No

12.Birth Place:Haryana
aryana /Outside Haryana (if Haryana then give below details)
if HYR Distt. ____________________Block/MC
_Block/MC ::___________________Village/Ward :_____________________
_______________________

13.Residing
Residing in HRY Since : _________
____________________ 14.Qualification:
.Qualification: ______________________________

15**.Occupation
.Occupation : ___________________________ 16.Annual
Annual Income : ___________________________
_______

17 Mobile No. : ______________________

_________________________ 18.Email : ______________________________
____________________

19 PAN No. : _______________________________

* Relationship with Head of family (HOF) : Wife/Son/Daughter/Father/Mother/Brother/Sister/etc.
**Occupation
pation : Farmer/Labour/State Govt. emp/Central or PSU emp/Private Industry/Housewife/ Student/Infant/Business/Construction
worker/Unorganised Labour/Unemployed etc (Head of family relationship will be SELF)
*** Marital Status : Married/Unmarried/Widow/Divo
Married/Unmarried/Widow/Divorced
Municipal Corporation, Gurugram Website: http://meraparivar.
http://meraparivar.haryana.gov.in NIC Haryana
Member-2 Details Page-2
1.Aadhaar No. _____________________________________ (12 digit)

2. Name (as in aadhaar)___________________________________________ (Capital letters)

3*.Relation with HOF:______________________ 4. Sex: Male/Female/Other 5. Date of Birth : _________

6. Father Name: __________________________________________

7. Mother Name: _________________________________________

8***. Marital Status :_______________________ 9. Spouse Name: _____________________________

10.Divyang : Yes/No 11.Govt. Employee : Yes/No

12.Birth Place: Haryana /Outside Haryana (if Haryana then 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 : ___________________________________

19 PAN No. : _______________________________

Member-3 Details
1.Aadhaar No. _____________________________________ (12 digit)

2. Name (as in aadhaar)___________________________________________ (Capital letters)

3*.Relation with HOF:______________________ 4. Sex: Male/Female/Other 5. Date of Birth : _________

6. Father Name: __________________________________________

7. Mother Name: _________________________________________

8***. Marital Status :_______________________ 9. Spouse Name: _____________________________

10.Divyang : Yes/No 11.Govt. Employee : Yes/No

12.Birth Place: Haryana /Outside Haryana (if Haryana then 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 : ___________________________________

19 PAN No. : _______________________________

(Use additional sheet if more members are in family, name spellings should be same as in aadhaar card, attach photocopy 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/Unemployed etc (Head of family relationship will be SELF)
*** Marital Status : Married/Unmarried/Widow/Divorced
Municipal Corporation, Gurugram Website: http://meraparivar.haryana.gov.in NIC Haryana