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    Family Member Certificate Form

    Uploaded by

    Maheshrok Naga
    The document appears to be an application form for a family membership certificate, requesting details about the applicant and deceased individual, including names, addresses, contact information, Aadhar numbers, reason and place of death. The form collects information on family members of the deceased and requires uploading documents like an affidavit, proof of relationship to the deceased, and a death certificate.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Family Member Certificate Form

    Uploaded by

    Maheshrok Naga
    1K views2 pages
    The document appears to be an application form for a family membership certificate, requesting details about the applicant and deceased individual, including names, addresses, contact information, Aadhar numbers, reason and place of death. The form collects information on family members of the deceased and requires uploading documents like an affidavit, proof of relationship to the deceased, and a death certificate.

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    © © All Rights Reserved

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    DOCX, PDF, TXT or read online from Scribd

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    The document appears to be an application form for a family membership certificate, requesting details about the applicant and deceased individual, including names, addresses, contact information, Aadhar numbers, reason and place of death. The form collects information on family members of the deceased and requires uploading documents like an affidavit, proof of relationship to the deceased, and a death certificate.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views2 pages

    Family Member Certificate Form

    Uploaded by

    Maheshrok Naga
    The document appears to be an application form for a family membership certificate, requesting details about the applicant and deceased individual, including names, addresses, contact information, Aadhar numbers, reason and place of death. The form collects information on family members of the deceased and requires uploading documents like an affidavit, proof of relationship to the deceased, and a death certificate.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Fa

    mily membership certificate -Application Form

    Applicant Details

    AADHAAR Card Number *:____________________________

    Applicant Name * :_____________________________ Relation Name* ______________________________

    Gender*:  Male  Female Date of Birth* (DD/MM/YYYY): _________________________________

    Permanent Address:

    Door No : ______________________________ Locality / Land Mark : __________________________

    District*:_______________________________ Mandal*:__________________________

    Village / Ward *:______________________________ Pin Code : ______________

    Present Address:

    Door No : ______________________________ Locality / Land Mark : __________________________

    State*:______________________ District*:____________________ Mandal*:__________________________

    Village / Ward *:______________________________________________ Pin Code : __________________

    Mobile * : ________________________________ Phone :_______________________________

    E-Mail: ________________________________ Remarks :_______________________________

    Ration card NO :_______________________ Delivery Type*:  Manual  Local post Non Local post

    Deceased Details:

    Deceased Name* : ______________________ father/Husband Name * :_____________________________

    Date of Death (DD/MM/YYYY)* : _____________________

    Reason for Death* :  Accident Floods / Cyclones / Thunder Bolt Fire Accident  Drowning

     Collapse of buildings/Bridges  Ill health  General Death  Suicide  Missing  Murder

    Occupation*:  State Government Services  Central Government Services  Public sector under takings
     Cooli  Agriculture Labor  Rickshaw Puller / Auto / Taxi / Lorry drivers/cleaners  Building
    construction workers  Working in factories  Fishing  Other Occupations  Handloom Worker 
    Retired Employee  Farmer  Business Man  Pensioner

    AADHAAR Card Number: _______________________ Death place *____________________________________

    Aadhaar Enrolment Number: Format (1234/12345/12345):______________________________


    2.Name of the Family 3.Age* 4.Gender 5.Relationship with Maritial status 6.Aadhar
    Member* Deceased* Number(UID) *

    Documents List:
    (NOTE: 1.Total size of Upload Document should not exceed 3 MB.2. All Upload Documents should be in PDF Format Only)

    1. Application Form*
    2. A notarized affidavit containing Name, Age and Relationship with deceased.*
    3. Document (Ration card/ Voter ID Card/ Passport/ Passbook, Aadhar cards, etc.) indicating the
    relationship of the applicant with the deceased*
    4. Death Certificate/FIR*

    Applicant’s Signature

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