District/Municipality /Village/Panchayat/Mohilla/Ward/House No.
|1. Shri/Smt :-
2. Name of Fathers or Husband:-
3. Full Address:-
4. Categories:- SC/ST/Woman/Landless/Widow/General.
5. Age on the date of the applicant :-
6. Identification mark of the applicant :-
7. I solemnly affirm that :-
1. I do not have any family income of Rs. 5000/- per annum or above.
2. I have/have not applied previously for grant of Old Age pension under NSAP.
3. I am a resident of .
(District/State) where I have been residing during the three years
immediately preceding the date of this application.
4. I declare that the information furnished in this application is true and
correct to the best of my knowledge and belief .
Place :- Signature of Thump impression
Date :- of the applicant
II (To be filled up by the enquiry team)
|1. Age (65 years or above) :-
2. Income/Destination :-
3. Category, Domicile :-
4. Whether applying FOR the first time if not, the decision on the
5. Whether the application belong under the proverty line:-
6. Recommendation :-
Date :- Signature of the Verifying person
Municipal Councillor/Village Authority/
Note :- This application should be sent with full particulars to the B.D.O/C.D.P.O, ICDS Project Concerned.
RECOMMENDATION OF THE B.D.O/C.D.P.O ICDS PROJECT
Signature of B.D.O/C.D.P.O, ICDS Project
Countersigned by S.D.O concerned.