Application form : Demand Survey notice 09/2009

DEMAND SURVEY APPLICATION FORM

Cost of application form as given in notification  ( Non-refundable.)

	Application No.
To		Affix Pass port
The Executive Engineer (Housing),		size photograph
___________________________________
___________________________________
___________________________________
Dear Sir,

I request you for registration of my name for allotment of house / flat / plot in the A.P.Housing Board Scheme on outright sale basis (100% payment)

Locality	Category	Tentative Cost	Amount paid	D.D. Particulars
		of	(EMD +	(DD No. date and
		house/flat/plot	application cost )	bank’s name) **
	Sampoornam
	Sampada
	Swarajyam
	Siddhi

** DD in favour of “EXECUTIVE ENGINEER ( concerned ) , A.P.HOUSING BOARD “

Name of the Applicant : _________________________________________Male  / Female  Father’s / Husband’s / Guardian’s Name : _______________________________ Age: _________

Occupation_____________________________Address:__________________________________

_______________________________________________________________________________

Phone:_________________; Mobile No.___________________; E-Mail : ___________________

1)     Date of Birth / Age (enclose authenticated certificate. Persons whose : date of birth is not recorded anywhere shall enclose age certif icate obtained from any Doctor)

2)     No House Certificate: The applicant should not own a house / flat : on his / her name or in the name of spouse or minor children or other dependents of his / her family. To that effect he / she should enclose No House / Flat Certificate duly signed by Gazetted Officer.

3)          Total monthly gross income through all sources (enclose : Rs. authenticated certificate like pay slip, IT return [Salary] etc.)

4)           Whether the applicant belongs to any one of the reserved categories. If so, proof shall be enclosed. If the applicant falls under more than one of the categories for which reservation is made, he/she shall choose only one reserved category under which he/she desires his/ her application (tick v whichever applicable) [as per G.O.Ms.No.63,Housing, dt.06/08/97]

Defense

SC

ST

BC

State

PH

Freedom

Open

Govt.

Fighters

category

Servants

Note : i) SC, ST and BC applicants shall enclose a certificate to that effect issued by the MRO.

ii) Physically handicapped applicants shall enclose a certificate to that effect from Medical Officer (Orthopedic), Government Hospital.

iii)  Applicants under the category of Freedom Fighters shall enclose a copy of the Pension Payment Order issued by the Government.

5)      Name   of   the   Nominee   (as   declared   in   the   Nomination   form   enclosed)   :

___________________________________________

6)      Family Member Particulars :

Sl.	Name of the Family	Age	Relationship with the	Occupation
No.	Member		applicants

DECLARATION

I hereby declare that the information given by me in the above application is true and correct and if it is later on noticed to be false or untrue my application under reference should be treated as cancelled by forfeiting EMD paid and if I have been successful in getting a flat on the basis of false or untrue information the allotment may be treated as void ab-initio.

I have read the terms and conditions for the allotment of flats by A.P. Housing Board contained herein on the regulations and the instructions to the applicants.

I agree to abide by them and such other conditions or alterations and also by the Regulations of the Authority which may be made from time to time in this regard.

Place    :

Date     :

SIGNATURE OF APPLICANT

AGE CERTIFICATE

( See Column – 1 of application form )

( To be submitted if no other certificate showing date of birth is available )

Certified that Sri / Smt. / Kum. ___________________________________________________

S/o. W/o. D/o. ____________________________________ is aged about ________ years by

appearance.

Date :

Place :

Signature  of the Doctor

with Official Seal

NO HOUSE CERTIFICATE

( See Column – 2 of application form )

This  is  to Certified that Sri / Smt. / Kum. ___________________________________

S/o.W/o.D/o.____________________________R/o. ________________________________ does not own a house / flat in the Municipal Limits of ____________, either in his / her own name or in the name of his wife / her husband (as the case may be) or in the name of his / her minor children.

Date :

Place :

Signature  of the Gazetted Officer / Employer

with Official Seal

INCOME CERTIFICATE

(See Column – 3 of application form )

This is to certify that Sri / Smt. / Kum. ___________________________________________

_S/o. W/o. D/o. ________________________________________ is known to me personally and his / her total monthly income is Rs._____________ in words (Rupees

_________________________________ ).

Date :

Place :

Signature of the Gazetted Officer / Employer :

Full Name :

Designation :

Office Seal :

CASTE CERTIFICATE

(See Column – 5 of application form )

This is to certify that Sri / Smt. / Kum. ________________________________________ S/o.

W/o. D/o. ______________________________________ R/O. _________________________________

Village _____________________ Mandal __________________ District belongs to ______________

Caste, Sl.No. __________________ in Group ____________________ of * Backward Class / Schedule

Caste / Schedule Tribe.
Date :
Place :	Mandal Revenue Officer
* Strike off whichever is not applicable.	with Office Seal

PHYSICALLY HANDICAPPED CERTIFICATE

(See Column – 5 of application form )

This is to certify that Sri / Smt. Kum. ________________________________________ S/o. W/o.

D/o.                                   _________________________________                                  R/o.

___________________________________________ is having ____________________ disability

and is a Physically Handicapped person.

Signature of Medical Officer

(Must not be below the rank of Civil Assistant Surgeon)

SERVICE CERTIFICATE

( See Column – 3 & 5 of application form )

( In case of State Government Employee )

This is to Certified that Sri / Smt. / Kum. _____________________________________ is working in this

Department as _______________________________________________________ from _________________ and

is / her monthly salary is Rs. _________________ (Gross).

Date :

Place :

Signature  of the Employer :

Full Name :

Designation :

Office Seal :

NOMINATION FORM

(See Column – 6 of application form)

I,  _______________________________  S  /  D  /  W  /  of  ______________________________

applicant       of        HIG/MIG        house/flat        at        _______________      hereby        nominate

_____________________________ aged __________ years who is my _________________ and whose address is __ _________________________________________________________________________

as the person to whom the said house / flat shall be transferred / for refund of EMD in the event of my death. Executed by me this ________ day of _________________________, 2008.

Specimen Signature / Thumb impress of Nominee

1.

2.

Witness :-

Signature of the applicant / Allottee.

Signature Full Name : Occupation :

Address in full :