Annexure 3

Beneficiary Survey Form for all verticals of PMAY-U 2.0

(To be filled by States/UTs/ULBs for Sanctioning projects by CSMC)

Required Information of Beneficiary

S. No. Required field Information

1 District GUNTUR
2 Mandal MANGALAGIRI (URBAN)
3 Village 16TH WARD
4 Name of head of the Family VARADA VANI
5 Aadhaar/Virtual Aadhaar ID XXXXXXXX6479
6 PAN Card (if available) -
7 Date of Birth [dd/mm/yyyy] 01/04/1994
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 Regular Wage
14 Occupation of the head of the family Others
15 Education Qualification up to Matric
16 Household Category LIG
17 Whether the family owns pucca house anywhere in NO
India
18 Average annual household income (in ) 96000
19 Religion HINDU
20 Marital Status Married
Spouse name RAVI KUMAR
Aadhaar/Virtual Aadhaar ID of Spouse XXXXXXXX6847
21 Special Focus Group Others
22 Category BC
 Sub Category Padmasali(Sl.No.-17)
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 NO
Availability of Land -
Measurements of the site(In Feet) -
25 Preferred component of Scheme Affordable Housing in Partnership(AHP)
26 Present Address:
a. House/Flat/Door No 8-414
b. Name of the Street BARGAVAPETA
c. City/Town MANGALAGIRI
d. District GUNTUR
e. State ANDHRAPRADESH
f. Mobile No. 8885759384
g. E-mail -
h. Pin code 522503
27 Permanent Address [Mark Check if same as Present
Address]:
a. House/Flat/Door No 8-414
b. Name of the Street BARGAVAPETA
c. City/Town MANGALAGIRI
d. District GUNTUR
e. State ANDHRAPRADESH
f. Mobile No. 8885759384
g. E-mail -
h. Pin code 522503
28 Address of the proposed House/ Flat under PMAY -U
2.0
a. House/Flat/Door No -
b. Name of the Street -
c. City/Town -
d. District -
e. State -
f. Mobile No. -
g. E-mail -
h. Pin code -
29 No. of years residing in the present city/town 15
30 No. of years residing in the present city/town 15
31 Type of the house based on roof type Pucca(CC & Stone Slab)
32 Details of family members
Name Relation Age Gender Occupation Aadhaar No.
ship
VARADA Son Male 30-09-2015 Others X21898187631
LOKESH NAGA
MANIKANTA
VARADA RAVI Husband Male 30-04-1984 Others X90766416847
KUMAR
33 Bank Details
a. Bank account number -
b. Name of the Bank -
c. Branch -
d. IFSC Code of Bank -
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. 2804885323
36 Have you availed benefit under any Central/State NO
sponsored Schemes
Scheme name -
37 Signature/Thumb Impression of Head of Household 1737805581217_WhatsAppImage2025-01-
25at5.14.38PM.jpeg
 38 Signature of representative of ULB in-charge 0678150

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

ii. for de-duplication with the previous housing Scheme, PMAY-U 2.0 (all verticals including Interest Subsidy
Scheme) and also for de-duplication with other housing Schemes such as PMAY (Gramin) etc.

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: VARADA VANI

Masked Aadhaar Number: XXXXXXXX6479
Mobile Number: 8885759384
Enclosure: Copy of the Aadhaar Id self-attested.

Signature of Applicant

Date:25-01-2025 Place: GUNTUR

Income Certificate copy