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crog&d,5 SaruSo
YSR PENSION KANUKA FIELD VERIFICATION FORM

Secretariat Name : Anr[q vor c.r.,. Secretariat Code : \O\aO3ztr1

Name of the Applicart;9.,J*.. R^^,-:,ao Aadhar N mbe.: 2? tiG4-8)-\6\6
Name of the Father/ Husband : App^tJi1^ Habitation: -A
^A
t^.cvcorcln
Gender: M Age: tG Date of Bi.th : ot/dt /t16 + Caste & Sub-Caste :-Slry\elr:-
Caste Certificate No: C6{),)i)2:1 042+32Lr I ncome Certificate l'L2 }\ 2) rth+ri t c
No:: 1

RiceCard Number: 23\51 58746 Mobile Numbei: 13't361oi 53

Volunteer Nanre i Volunl.eer lD : Lel5Q34S oo )
TvDe
"'
OiPension: Fx^.*
__ A",*, tt
{1

S. No Category As Per System Validation As Per Field Verilication

1. Family Income for a Month Rs. .............. Per Month Rs. .............. Per Month

2. Dry Land holding of Family Acres .....:::=....... Acres

-*............
3. Wet Land holding ol Family .-:...... Acres Acres
=...
Four-Wheeler in Familv Yes/No t{o Yes/No t.lo
5. Covt. Employee jn Family Yes/No Yes/No N{^
NJo
6. Eieciricity Consunlptioli -.......L..1=.... units ..,.....= Units
-o-....
7. Property in Municipal Area ......... in Sq. Ft. .-.....--..-.. in sq. rt.
B. lncome iax Payee in Family Yes/No n f^ Yes/No \\[cr
Any other Pension in the Family Yes/No NLo YeslNo iS o

Remarks:

Eligible/lne+jgible eTW-

I Solemnity state that the above-mentioned particulars al'e true to the best ofmy knowledge
and beliefand lh3t itconceals nothirlgancl thatro part ofit is false. In case iffbund futurc that lhe
deciaration given above is false, I am liable lbr prosecution.

tl I ul-- ,-,!ad., L'LLa

f'
Signature of Welfare and Education assistant