Annexure 3

Beneficiary Survey Form for all verticals of PMAY-U 2.0

Required Information of Beneficiary

S. No. Required field Information

1 District PALNADU
2 Mandal VELDURTHI
3 Village LOYAPALLI
4 Name of head of the Family HANIMI BAI
5 Aadhaar/Virtual Aadhaar ID XXXXXXXX1241
6 PAN Card (if available) -
7 Date of Birth [dd/mm/yyyy] 01/01/1993
8 Sex Female
9 Father’s name -
10 Aadhaar/Virtual Aadhaar ID of Father -
11 Mother’s name -
12 Aadhaar/Virtual Aadhaar ID of Mother -
13 Employment Status Labour
14 Occupation of the head of the family Agricultural Labour
15 Education Qualification No Education
16 Household Category EWS
17 Whether the family owns pucca house anywhere in NO
India
18 Average annual household income (in ) 80000
19 Religion HINDU
20 Marital Status Married
Spouse name MANTRU NAIK
Aadhaar/Virtual Aadhaar ID of Spouse XXXXXXXX0573
21 Special Focus Group Others
22 Category ST
 Sub Category Sugalis(Sl.No-29)
23 Whether residing outside Statutory Town/ ULB, but NO
within Notified Planning/Development area
a.Name of Development Authority/Notified Planning -
Area
b.Name of District -
c.Name of Mandal -
d.Name of Village -
24 Whether site is avaliable or not YES
Availability of Land PocessionCertificate
Measurements of the site(In Feet) 750
25 Preferred component of Scheme Beneficiary-Led Construction(Blc)
26 Present Address:
a. House/Flat/Door No 9-8
b. Name of the Street PICHAIAH BAVI THANDA
c. City/Town veldurthi
d. District Palnadu
e. State ANDHRA PRADESH
f. Mobile No. 9133221952
g. E-mail -
h. Pin code 522613
27 Permanent Address [Mark Check if same as Present
Address]:
a. House/Flat/Door No 9-8
b. Name of the Street PICHAIAH BAVI THANDA
c. City/Town veldurthi
d. District Palnadu
e. State ANDHRA PRADESH
f. Mobile No. 9133221952
g. E-mail -
h. Pin code 522613
28 Address of the proposed House/ Flat under PMAY -U
2.0
a. House/Flat/Door No 9-8
b. Name of the Street PITCHAIAH BAVI THANDA
c. City/Town veldurthi
d. District Palnadu
e. State ANDHRA PRADESH
f. Mobile No. 9133221952
g. E-mail -
h. Pin code 522613
29 No. of years residing in the present city/town 20
30 No. of years residing in the present city/town 20
31 Type of the house based on roof type Kutcha(Grass/thatched,Tarpaulin,wooden)
32 Details of family members
Name Relation Age Gender Occupation Aadhaar No.
ship
BANAVATH Husband Male 01-01-1991 Agricultural X25793040573
MANTRU NAIK Labour
NAGA LAKSHMI Daughter Female 04-10-2013 Others X19851967855
BAI
33 Bank Details
a. Bank account number 701410031075077
b. Name of the Bank CHAITANYA GODAVARI GRAMEENA
BANK
c. Branch SIRIGIRIPADU
d. IFSC Code of Bank UBIN0CG7014
34 Do you have Jan Dhan Yojana account? (Yes/No) NO
35 Does the family have a BPL Card (Yes/No) YES
Provide BPL Card No. 2805823536
36 Have you availed benefit under any Central/State NO
sponsored Schemes
Scheme name -
37 Signature/Thumb Impression of Head of Household 1738252123118_IMG20250130091715~3.j
pg
 38 Signature of representative of ULB in-charge 0675275

Note 1: All details should be filled up as per Aadhaar only.

Note 2: Consent for Aadhaar Authentication:

a) I hereby state that I have no objection in authenticating myself with Aadhaar-based authentication and give
consent to provide my Aadhaar number, Biometric, and/or One Time Password (OTP) data for Aadhaar-based
authentication for the purposes of availing benefits of owning a pucca house under Pradhan Mantri Awas Yojana
- Urban 2.0 (PMAY-U 2.0). I understand that the Aadhaar number, Biometrics, and/or OTP provided for
authentication shall be used:

i. for authenticating my identity and

b) I understand that PMAY-U 2.0, Ministry of Housing and Urban Affairs, Government of India shall ensure
security and confidentiality of my personal identity data provided for the purpose of Aadhaar-based
authentication.

c) I hereby declare that the information provided hereunder is correct.

Name: HANIMI BAI

Signature of Applicant

Date:30-01-2025 Place: PALNADU