Cost : ` 1/-

APPLICATION FOR EX- GRATIA UNDER APATHBANDHU SCHEME

TO
The Collector,

______________________ District.

1. Name of the Applicant : _______________________________________________________________________________

(In Block Letters)

With Residential Address :______________________________________________________________________________

___________________________________________________________________________________________________
2. Name of the Deceased : _______________________________________________________________________________
(In Block Letters)

Name of the Father / husband : __________________________________________________________________________

(a) Residential Address : _______________________________________________________________________________
(b) Age : __________ (c) Occupation: _______________________________ (d) Annual Income ____________________
3. Relationship with deceased : _________________ 4. Date of Accident _____________ 5. Date of Death :_____________
6. Place of death (with details) : ___________________________________________________________________________
(i) H.No : ___________________ (ii) Locality (Police Station) : ______________________________________________
iii) Mandal : ____________________________________ (iv) District : _________________________________________
7. Cause of Death : _____________________________________________________________________________________
8. Name of family members / legal heirs particulars
S.No

Relationship with deceased

Age

Occupation

Income

Documents to be enclosed:-.
(a) Death Certificate
(b) FIR
(c) Report of post Mortem/Panchanama
The particulars furnished above by me are true and correct to the best of my knowledge.
The particulars furnished by me, if found false, I will be responsible for legal action.

Place:
Date:

Signature of the Applicant