Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697804007858.pdf (India)
REVENUE DEPARTMENT, GOVT.

OF NCT OF DELHI APPLICATION FORM – SURVIVING MEMBER CERTIFICATE APPLICANT DETAILS 1. e-DistrictRegistration Number : (For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number) 2.

UID (AADHAAR) No : OR 3.

Name of Applicant : ___________________________________________ 4.

Name of Father : ___________________________________________ 5.

Name of Mother : ___________________________________________ 6.
Name of Spouse : ___________________________________________ 7.

Gender : Male Female Other 8.

Date of Birth : DD MM YYYY Applicant color Passport Size Photograph Size – 5 x 4.5 (Cm.)

Or 2 x 1.75 (Inch) 9.

Mobile No: Email address: _____________@__________ 10.
Present Address : House Name/No : ______________________ Locality : ______________________ Sub- division : ______________________ State : ______________________ PIN Code : Sub-Locality : ______________________ Village/Town : ______________________ District : ______________________ Country : _______________________ 11.
Whether the Present and Permanent Address is same : Yes No 12. if No, Permanent Address : House Name/No : ______________________ Locality : ______________________ Sub- division : ______________________ State : ______________________ PIN Code : Sub-Locality : ______________________ Village/Town : ______________________ District : ______________________ Country : _______________________ 13.

Purpose of Certificate : ___________________________________ 14.
Relationship of the Applicant with Deceased : __________________________________ Details Of Deceased 15.

Name of Deceased : ___________________________________________ 16.

Father’s / Husband’s Name : ___________________________________________ 17.

Mother’s Name : ___________________________________________ 18.

Gender : Male Female Other Deceased Person colour Passport Size Photograph Size – 5 x 4.5 (Cm.)

Or 2 x 1.75 (Inch) 19.

Death Certificate No.


:___________________ (Attach death certificate along with Application) Certificate Issue Date : Date of Death : DD MM YYYY DD MM YYYY APPLICATION FORM – SURVIVING MEMBER CERTIFICATE 20.

Details of Surviving Family Members S.No Name Age (In Years) Relation with Deceased Photo 1.

2.

3.

4.

Identity Proof (Please tick one, provide the document No.
and attach the same) Aadhaar Card Passport Driving License PAN Card Ration Card with Photograph Voter ID Card Any Govt.

recognized Document Document Number : Identity Proof (Please tick one, provide the document No.

and attach the same) Aadhaar Card Passport Driving License PAN Card Ration Card with Photograph Voter ID Card Any Govt.

recognized Document Document Number : Identity Proof (Please tick one, provide the document No.


and attach the same) Aadhaar Card Passport Driving License PAN Card Ration Card with Photograph Voter ID Card Any Govt.

recognized Document Document Number : Colour Passport Size Photograph Size – 5 x 4.5 (Cm.)

Or 2 x 1.75 (Inch Colour Passport Size Photograph Size – 5 x 4.5 (Cm.)


Or 2 x 1.75 (Inch Colour Passport Size Photograph Size – 5 x 4.5 (Cm.)

Or 2 x 1.75 (Inch If Surviving members are more than 4, Please attach list of surviving members with this application form in above specified format.

21.

Identity Proof of Applicant (Please tick one, provide the document No.

and attach the same ) Aadhaar Card PAN Card Ration Card with Photograph Voter ID Card Passport Driving License Any Govt.
recognized document Document No : 22.

Present Address Proof of Applicant (Please tick one, provide the document No.

and attach the same ) AADHAR Card Voter ID Card Driving License Passport Ration Card Electricity Bill DISCOM Name___________ Water Bill Utility Name _____________________ Gas Bill Comp Name _____________ Telephone Bill Company name_______________ Any Govt.

recognized document Rent Agreement (Registered) Bank Passbook Document No : .

.

23.
.

23.

Permanent Address Proof of Applicant (Please tick one, provide the document No.

and attach the same ) AADHAR Card Voter ID Card Driving License Passport Ration Card Electricity Bill DISCOM Name___________ Water Bill Utility Name _____________________ Gas Bill Comp Name _____________ Telephone Bill Company name_______________ Any other Govt.

recognized document Rent Agreement (Registered) Bank Passbook Document No : .

.
.

Date: DD MM 20YY Applicant Signature : Place: ______________________ APPLICATION FORM – SURVIVING MEMBER CERTIFICATE 24.

Self-Declaration I ________________________________________S/o/D/o Sh._______________________________ aged _______________R/o____________________________________________________________ Verify as Under: I.

That the above contents are correct to the best of my knowledge and belief and nothing has been concealed therein.

I further affirm that- II.


I am aware that in case the information furnished above is found to be incorrect, I shall be liable for prosecution under section 177 & 191 of the Indian Penal Code, which stipulates as under:- 177.
Furnishing False Information- whoever, being legally bound to furnish information on any subject to any public servant, as such, furnishes, as true, information on the subject which he knows or has a reason to believe to be false, shall be punished with simple imprisonment for a term which may extend to six months, or fine which may extend to one thousand rupees, or with both; Or, if the information which he is legally bound to give respects the commission of an offence, or is required for the purpose of preventing the commission of an offence, or in order to the apprehension of an offender, with imprisonment of either description for a term which may extend to two years, or with fine, or with both.
191.

Giving false evidence- Whoever being legally bound by an oath or by an express provision of law to state the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false, and which he either knows or believes to be false or does not believe to be true, is said to give false evidence.

Providing any false evidance shall be punishable under section 193 of IPC, 1860 which provides imprisonment for a term upto three years and fine.

III.
III.

Date: DD MM 20YY Place: ______________________ Signature of Beneficiary : (Parents Signature in case of Minor) APPLICATION FORM – SURVIVING MEMBER CERTIFICATE