SSEPD::Social Security & Empowerment of Persons With Disabilities Department

Madhu Babu Pension Yojana Application Form

Madhu Babu Pension Yojana Application Form
Pension Type	:	Widow Pension		Name	:	MAHLA HEMBRAM
Father's/Spouse Name	:	LATE LASA HEMBRAM		DOB	:	09-03-1987
AGE	:	35		Aadhar No	:	Not Captured
	Gender	:	Female
Mobile No	:	9348983029		District	:	MAYURBHANJ
Sub-division	:	BARIPADA		Address Type	:	Block
Block	:	RASGOVINDPUR		GP	:	DEBASOLE
Village	:	MUSAMARI		Habitation	:	MUSAMARI
House No/Plot No	:	MUSAMARI		PIN	:	757016
Social Category(Caste)	:	ST
The parental/family income of the applicant is not more than Rs.60,000/-per annum.	:	Yes		Has not been convicted of any criminal offence involving moral turpitude.	:	Yes
Is a permanent resident/domicile of Odisha since 20 years.	:	Yes		Application Number	:	SSEPD/BNFAPP/MBPY/06/16/2022/839563

Bank Account Details
Bank Account Type	:	Single Account	Account Holder Name	:	MAHLA HEMBRAM
Account Number	:	547510110006883	IFSC Code	:	BKID0005475
Bank Name	:	BANK OF INDIA	Branch Name	:	BACHURIPAL

Declaration

I Mr/Mrs MAHLA HEMBRAM truely declare that:

The parental/family income of the applicant is not more than Rs.60,000/-per annum.

Has not been convicted of any criminal offence involving moral turpitude.

Is a permanent resident/domicile of Odisha since 20 years.

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately.In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it and that my pension will be terminated.

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