Cost : ` 1/-

FORM OF APPLICATION CLAIMING FAMILY BENEFIT(FB) UNDER NSAP

PART-1
(To be filled in by the Head of the Surviving family) District_____________________________ Mandal____________________________

1. Name of the applicant Sri/Smt. 2. Full address

: ___________________________________________ : ___________________________________________ ___________________________________________ ___________________________________________

3. Name of the deceased primary bread winner 4. Relationship of the deceased with the applicant 5. Date of death of primary bread winner

: ___________________________________________ : ___________________________________________ : ___________________________________________

6. I solemnly affirm that (a) I do not have any family income of Rs.5,000/- per month or more. (b) I am the surviving head of the family of the deceased Primary bread winner. (c) The Primary bread winner died at the age of ____________ (Proof like Death Certificate to be attached) (d) The deceased was resident of District Where he had been residing for last 3 years immediately preceding the death. (e) I declare that the information furnished in the application is true and correct to the best of my knowledge and belief.
Place: Date: Signature of Applicant

PART-II
(To be filled by the Local Enquiry Team) We certify after due enquiry as follows that: 1. The deceased was the Primary bread winner of the house hold 2. The deceased had been residing in the district for three years before death. 3. The applicant is the surviving head of the family 4. The age of the primary bread winner at the time of death is ____________years. 5. We recommend/do not recommend for sanction of family benefit. 6. This claim is received on_________________________ and is being forwarded to Medical Officer/P.O. ICDs.

Place: Date: Signature of Enquiry Officer with Designation

SERVICES OFFERED
Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Service Extract of Adangal / Pahani Extract of ROR 1B Copy of FMB Copy of Village Map F-Line Petitions Sub-Division of Lands Mutation of Entries in Revenue Records Income Certificate Residence Certificate Integrated Certificate (Caste-Nativity-Date of Birth) OBC Caste Certificate EBC Certificate Agricultural Income Certificate No Earning Member Certificate Family Member Certificate (Social Security Schemes & Govt. Employees / Pensioners) Issue of Encumbrance Certificate Certified Copy of Registration Document Money Lending License Allopathic Medical Care Registration Apathbandhu Scheme NFBS Application No Objection Certificate (Lands) Pawn Broker License School Registration Birth Certificate - GHMC Death Certificate - GHMC Birth Certificate Corrections - GHMC Death Certificate Corrections - GHMC Service Level 15 Minutes * 15 Minutes * 15 Minutes * 5 Days 30 Days 30 Days 45 Days 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 30 days 2nd time & thereafter - 15 minutes 1st time - 30 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes 1st time - 7 days 2nd time & thereafter - 15 minutes Same day, if submitted by 2 pm 15 minutes Fresh - 45 days Renewal - 30 days 90 Days 10 Days 1 Week 30 Days Fresh - 45 days Renewal - 30 days 1 Week 15 Mins. (Category-A) 15 Mins. (Category-A) 6 Working Days 6 Working Days Service Charges (`) 25/25/25/35/35/35/35/35/35/35/35/35/35/35/35/-

16 17 18 19 20 21 22 23 24 25 26 27 28

25/25/35/35/35/35/35/35/35/25/- per transaction + statutory charges 5/- per additional copy 25/- per transaction + statutory charges 5/- per additional copy 60/- + 25/- per copy of certificate 60/- + 25/- per copy of certificate 10/- + 25/- per copy of certificate (after one year)

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Child Name Inclusion - GHMC Non Availability Certificate Birth - GHMC

6 Working Days (within one year) 3 Working Days

25/- per copy of certificate 25/- per copy of certificate

NOTE : 1. Postal charges extra. 2. *Subject to availability of online digital records, otherwise the request will be processed within 7 days. 3. Printing of additional pages at ` 2/- per page.

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