The land of the Dancing Deer


                                                        ANNEXURE V                                        BACK
Form F. B I
Application Form for Family Benefit.
(To be filled up by the applicant/ Nominee)

 1. Name of deceased :-
 2. Age of deceased :-
 3. Full Address:-
 4. Name of Father/ Husband of deceased :-
 5. Date of Expiry :-
 6. Cause of death :- i) Natural ii) Accidental.
 7. Name of applicant/Nominee and address :-
 8. Relation with the deceased :-
 9. Income of the deceased/bereaved family (Below Rs. 5,000/- per annum or more)
10. List of Members of the deceased :-
11. Whether there is landed property of the decease/bereaved family.
12. No objection certificate from other family members of the deceased.


                                                                                                           Signature of applicant/Nominee

List of documents to be enclosed :-

  1. Death certificate from the Registrar of Birth and Death/ Competent authority.
  2. Certificate from Doctor for the cause of death.
  3. Certificate from the concerned Municipal Councillor/ Panchayat/ village Authority.
  4. S.D.O/ S.D.Cs report on

    i. List of family members who are dependent on the deceased (Please indicate Sex and relationship)
  i i. Income certificate.

1. An Affidavit from a Magistrate supporting all the facts.



                                                                II F B
                                       (to be filled up by the enquiry team)

  1. Age of the deceased :-
     (Age group 18 to 66 years)
  2. Income of the deceased :-
  3. Whether the deceased was the primary breadwinner of the family. State the conditions
      of the bereaved family.
  4. Whether the applicant/nominee is related with the deceased. State the relationship.
  5. Whether the bereaved family/ household belong under the poverty line.
  6. Recommendation :-

Date :- ..                                            Signature of verifying person
                                                                                    Municipal Councillor/Village Authority/
                                                                               Panchayat/Anganwadi Workers/TLC/VLWs.

                                                                                Full Address :

Note :- This application should be sent with full particulars to the BDO/CDPO ICDS project concerned.

Date :-

                        Recommendation of the BDO/CDPO ,ICDS project.

Countersigned by SDO concerned.