REVENUE DEPARTMENT, GOVT.
OF NCT OF DELHI
APPLICATION FORM – PERMANENT IDENTITY CARD TO THE DISABLED PERSON
BENEFICIARY DETAILS
1. e-DistrictRegistration Number :
(For already Registered User- Not to be filled in by first time Applicants or those having Aadhaar number)
OR
2. UID (AADHAAR) No :
a. Name of the Beneficiary : ___________________________________________
Beneficiary color
b. Name of Father : ___________________________________________
Passport Size
c. Name of Mother : ___________________________________________ Photograph
d. Name of Spouse : ___________________________________________ Size – 5 x 4.5 (Cm.)
e. Gender : Male Female Other Or
2 x 1.75 (Inch)
f. Date of Birth :
DD MM YYYY
3. Mobile No. : e-Mail ID :_________________@___________
(in case of minor, provide parents contact details)
4. Present Address (Address of Parents in case of Minor)
House Name/No : ______________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : ______________________
State : ______________________ Country : _______________________
PIN Code :
5. Whether the Present and Permanent Address is same : Yes No
if No, Permanent Address (Address of Parents in case of Minor)
House Name/No : ______________________ Sub-Locality : ______________________
Locality : ______________________ Village/Town : ______________________
Sub- division : ______________________ District : ______________________
State : ______________________ Country : _______________________
PIN Code :
6. Type of Disability :____________ 7. Percentage of Disability : ____________ %
8. Details of Medical Certificate (attach certificate along with application)
a. Disability Certificate No : __________________ c. Certificate Issuing Authority : ______________
b. Date of Issue :
DD MM 20YY
9. Identity Proof of Beneficiary(Please tick one, provide the document No. and attach the same )
Aadhaar Card Passport Letter (attested) from School Principal (for minor only)
Voter ID Card Ration Card with Photograph School ID Card (for minor only)
PAN Card Driving License Birth Certificate (for minor below 5 years only)
Any Govt. recognized document Document No :
10. Identity Proof of Parents ( in case parents applied on behalf of minor)(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 :
APPLICATION FORM – SURVIVING MEMBER CERTIFICATE
11. Present Address Proof of Beneficiary(or Parents in case of Minor) (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 _____________________ 1. Gas Bill Comp Name _____________
Telephone Bill Company name_______________ 91 Any Govt. recognized document
Rent Agreement (Registered) Bank Passbook Document
9 No :
12. Permanent Address Proof of Beneficiary(or Parents in case of Minor) (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 _____________________ 1. Gas Bill Comp Name _____________
Telephone Bill Company name_______________ 91 Any Govt. recognized document
Rent Agreement (Registered) Bank Passbook Document
9 No :
Declaration
I hereby solemnly affirm & declare that, all of the above furnished information, is true & correct to the best of my
knowledge. I am fully aware that furnishing incorrect or false or forged information will lead to punitive action against
me under the relevant statutory provisions.
Date:
DD MM 20YY
Beneficiary Signature :
Place: ______________________ (Parents Signature in case of Minor/disabled)
APPLICATION FORM – SURVIVING MEMBER CERTIFICATE