APPLICATION FORM FOR ORPHAN CERTIFICATE FROM THE ADDITIONAL DEPUTY     COMMISSIONER  PAPUM PARE DISTRICT 

                                                                        ARUNACHAL  PRADESH

  1. Name of applicant  (In block letter)  

  2. Name of person whom required        

  3. Pressent address, Village                                                     

  4.  Post Office                                           

  5.  Police Station                                     

  6.  District                                                 

  7. Tribes/Caste                                     

  8. Father's name                                      

  9.  Date of Death (with medical certificate)

  10. Mother name                                                     

  11.  Date of Death (with medical certificate) 

  12. Name of Guardian                                       

  13. Relationship with guardian                         

  14. Occupation                                                  

  15. Purpose of which certificate is required  

  16. Police verification report                          

  17. Name of witness                                         

                            1.

                            2.

                            3.

Signature of applicant

Date :

Place :

VERIFICATION

            I Shri ASM of village under Administration circle verified personally and statement furnished by the applicant are correct to the best of knowledge and belief.

( Name and Signature )

ASM/ZPM/MP/MLA/(with seal)

            Certified that the above particulars furnished by the applicant are the correct to the best of my knowledge and belief.

Palce :-

Dated :-

Signatur eof concerned Administration

Officers of the area

(With seal)