SADGRAHA – Shelter Humanity
A Cost Free Housing Project - Survey Form
Eligibility Screening
Is Scheduled Tribe (ST)?
ଆପଣ ଅନୁସୂଚିତ ଜନଜାତି କି?
Select
Yes - ହଁ
No - ନା
Own RCC House ?
ନିଜର ଛାତ ଘର ଅଛି କି?
Select
Yes - ହଁ
No - ନା
Received Any Govt Housing Before ?
କୋଣସି ସରକାରୀ ଅନୁଦାନ ଘର ମିଳିଛି କି?
Select
Yes - ହଁ
No - ନା
Land Patta Available in your Name?
ଆପଣଙ୍କ ନାମରେ ଜମି ପଟା ଉପଲବ୍ଧ କି?
Select
Yes - ହଁ
No - ନା
1. Basic Information
Name
Father / Spouse Name
Gender
Select
Male
Female
Other
Age
Mobile No
Aadhaar Number
2. Address Details
Village
P.O.
P.S.
Block
District
State
PIN Code
3. Family Details
Total Children
Male
Female
Sl.
Member Name
Relationship
Gender
Age
Education
Action
1
Child
Spouse
Father
Mother
Other
Male
Female
Other
Illiterate
Primary
Middle
High School
Higher Secondary
Graduate
Other
X
2
Child
Spouse
Father
Mother
Other
Male
Female
Other
Illiterate
Primary
Middle
High School
Higher Secondary
Graduate
Other
X
3
Child
Spouse
Father
Mother
Other
Male
Female
Other
Illiterate
Primary
Middle
High School
Higher Secondary
Graduate
Other
X
+ Add More Member
4. Land & Housing Details
Land Holding Area (Sq. Meter)
Survey No
Nature of Land
Field
Solid Land
Right on Land
Own
Lease
License
Holding Own House?
Yes
No
Road Access Facility?
Yes
No
5. Document Upload
Aadhaar Copy
Land Document
Own Photo with Land/House
Family Photo
6. Declaration
I declare that I have not received any previous housing benefit and will not pay money to any contractor.
Submit Survey