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APPLICATION FORM
(INCLUSION IN BPL 2002 SURVEY LIST)
* Indicates Mandatory field
* Select District
* Select Block
* Select Panchayat
* Village
* Name of the Applicant
* Father/ Husband’s Name
  House No.
Address Details
 Lane / Sahi
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  
Identification and Sub categorization of Poor (Please indicate Score)
Sl No. Socio-economic Indicators 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