GOVERNMENT OF ANDHRA PRADESH

GVWV and VSWS Department

Household Split Field Verification Form

Split Type Divorce

Secretariat Details
Secretariat Name Volunteer Name
Secretariat Code Cluster ID

Applicant Details
Application Number Application Date
Secretariat Name Secretariat Code

RESULTANT HOUSEHOLD 1
Address:
Citizen Name Aadhaar Marital Status Relationship status Remarks

RESULTANT HOUSEHOLD 2
Address:
Citizen Name Aadhaar Marital Status Relationship status Remarks
I have personally verified the original Divorce decree document. Yes No

Is Divorcee Decree matching the composition of the resultant Households? Yes No

I have personally visited and verified that the Divorcee Couple is living Separately. Yes No

Field Verifier Details

Employee Name Employee Designation
Inspection Time District Name
and Date
Recommendation Remarks

I solemnly swear that the above-mentioned particulars are true to the best of my knowledge and belief,
and it conceals nothing and that no part of it is false. In case if found in the future that the declaration
given above is false, I am liable for prosecution.

Signature of Applicant Signature of Employee (Verifier)