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Intensive Household Survey 2014

Check Slip
To be filled by you
5. Pincode No.
Sl.No.

Item

Details

House water tap


connection (A10 & 11)

Yes*

No*

Property tax assessment


Yes*
( A12& 13)

No*

Gas/LPG connection
( B8,9 & 10)
Electricity connection
(C14,15 & 16)

Copy of Water Bill

If Yes CAN No.

Document
Yes*

Copy of PTIN Demand

If Yes PTIN No.

Yes*

No*

No*
Copy of LPG Gas Bill

If Yes Connection No.


Yes*

No*

Yes*

No*

Copy of Electricity Bill

Connection

Yes*

No*

If Yes Meter

Yes*

No*

Yes*

Yes*

No*

Copy :

No*

If Yes Meter No.


Bank Account
5

Bank Account
(D12 & 13)

If Yes Bank Name

Yes*

Branch

Account No.
Sex
M/F

Name

Card No.

Copy
(Y/N)

EID

Adhar Card (B21)


(of all Family Members)

Caste Certificate (B5) SC*

Birth Certificate (C5)

Copy of Certificate
ST*

OBC*

Yes*

OC*

Yes*

Yes*

No*
Copy of Certificate

No*

Any Disabled Person


9

No*

Yes*

No*
Copy of Certificate

No*
Yes*

Disability (E)

No*

SADAREM/Certificate No.
Item
10

11

Vehicle (G)

Land details (H)

Yes / No

No. of Vehicles

Registration No.

Motor Cycle/Scooter
3 Wheeler/ Auto
Car/Jeep
Air Conditioner
Pattedar Pass Book No.:

Copy of Pattedar Pass Book

Revenue Village :

Yes*

District :

To be filled by Enumerator

No*

Copy
(Y/N)

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