APPLICATION FOR FAMILY MEMBER /
PROPER PERSON CERTIFICATE
To
The Tahsildar,
………………………………Mandal.
Sir / Madam,
It is to bring to your notice that my father / husband / son / daughter
______________________________son/father/husband ____________________________ died
on ___________________________ date due to …………………………….. As certain dues
are to be received from the Government / Other Companies / Organisations, I required a Family
Member /. Proper Person Certificate. Details of my family members are furnished here under.
Sl. No. Name of the Family Member Age Sex Relationship with the Deceased
1.
2.
3.
4.
5.
2. I am herewith enclosing the following documents in support of my application.
a)Death Certificate dated…………………. Issued by…………………………….
b)Ration Card No.
3 I am also enclsing
the following with the application form
a) Challan for Rs.50/- dt………………………; Challan No…………………………
b) Notarized Affidavit of Family Members (Rs.10/-)
4. Hence, it is requested that after due enquiry the Family Members Certificate / Proper
Person Certificate my be issued.
5. The Proper Person Certificate may kindly be issued in favour of …………………….
…………………….………………… (Sl. No……….. above) to receive the dues if any from
Government / any other Organisation / Company etc., due to the death of the deceased.
( To be filled in only if proper person certificate is required)
Date:
Place:
:
Signature of the Applicant
AFFIDAVIT OF FAMILY MEMBERS
I, ………………………………. S/o, D/o ……………………………, age ……
years, residing at D.No.
………………………………………………………………………..
………………………… Nellore Mandal, Sri Potti Sriramulu Nellore District, do
hereby solemnly affirm and state as follows:-
1. I do hereby declare that my Father/Mother/Husband/Son/Daughter died on
…………………………………………, at ………………………………due to
illness. He has left behind the following family members.
Sl.No. Name of the family members Age Relationship with the
deceased
2. I am giving this affidavit on solemn declaration consciously believing it to
be true and in faith thereof.
The above stated facts are true and correct.
Date: Deponent.
Solemnly affirmed and executed.