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APPLICATION FORM
(EXCLUSION IN BPL 2002 SURVEY LIST)
* Indicates Mandatory field
* Select District
 Select Block
 Select Panchayat
* Select Village
* Select Family Id
* Name of the Applicant
* Father/ Husband’s Name
  House No.
Reason of application (Check any)
i.Not surveyed previously  
ii.Separation from the family  
iii.Migration from other village/ ULB  
iv.Verification/ Correction needed in the existing Survey List in the following  
A. Identification and Sub categorization of Poor (Please indicate areas where verification required)
1 Name of Head of Household
2 Father/ Husband’s Name
3 Age
4 Sex
5 Social Category
6 Average Monthly Income
7 Operational Land Type
8 Own land for IAY
9 Drinking Water Facility
B. Identification and Sub categorization of Poor (Please indicate Score)
Sl No. Socio-economic Indicators Existing Score Proposed Score
1 Operational Land Size Group
2 House Type
3 Availability of normal wear Clothing
4 Food Security
5 Sanitation
6 Ownership of Consumer Durables
7 Status of the highest Literate Adult
8 Labour Force
9 Means of Livelihood
10 Children Status
11 Type of Indebtedness
12 Migration
13 Assistance
  Total