ServicePlus- Ex-Gratia Financial Assistance to Family of COVID-19 victims

	GOVERNMENT OF TRIPURA Revenue Department
Application for Ex-Gratia Financial Assistance to the Family of the Victims of COVID-19
If you face any difficulty in Application please contact 0381-2416045

Claimant's Contact Details

Please enter your mobile number *

Enter your Email

Please Enter Death Certificate Number

Death Certificate Number

Details Of Person Expired due to COVID-19

Expired Person Name *

Father's / Husband's Name

Date of Birth *

Date Of Death

Gender.

Aadhaar No

Residential Address *

Date of Medical Certificate issued

Whether belongs to *

Issued by whom

Date of COVID 19 Diagnosis

Profession/ Occupation

Date Of Death hidden

Date of Medical Certificate issued hidden

Gender hidden

Expired Person Address Details

District *

Sub District *

Location Type *

Municipality *

Ward *

Area Name *

Municipal Corporation *

Ward *

Area Name *

Nagar Panchayat *

Ward *

Area Name *

Block *

Gram Panchayat *

Habitation/ Village Name *

ADC Block *

Village Council *

Habitation/ Village Name *

Police Station *

Quick Post Office List Search

Post Office & Pincode *

Survivor Details

Survival Certificate No.

Application Date

Date of Death

Details of the Family Members

Deceased Name

Survivor Details

Member Name

Relationship with the Deceased person

Identify Claimant

Member Name

Relationship with the Deceased person

Identify Claimant

.

Deceased First Name

Deceased Middle Name

Deceased Last Name

Claimant's Particulars

Claimant's Name *

Relationship with the Deceased person *

Father's / Husband's Name *

IFSC *

Bank Name

Bank Account No *

Date of Birth *

Gender *

Whether belongs to *

Aadhaar Number

Declared Annual Income *

Whether Employed *

Photograph of Claimant *

Claimant's Communication Address Details

District. *

Sub District *

Location Type *

Municipality *

Ward *

Area Name *

Municipal Corporation *

Ward *

Area Name *

Nagar Panchayat *

Ward *

Area Name *

Block *

Gram Panchayat *

Habitation/ Village Name *

ADC Block *

Village Council *

Habitation/ Village Name *

Police Station *

Quick Post Office List Search

Post Office & Pincode *

Supporting Document

Do you have Discharge Certificate ? *

Yes

No

Discharge Certificate No *

Discharge Date *

Do you have RTPCR/ RAT Test Report ? *

Yes

No

RTPCR Test Ref No *

Test Result Date *

Do you have Prescription ? *

Yes

No

Doctor Registration No *

Date of Prescription *

Do you have COVID Slip ? *

Yes

No

Covid Slip Ref No *

Date of COVID Slip *

Do you have IPD Slip ? *

Yes

No

IPD Slip Ref No *

Date of IPD Slip *

Do you have Admission Slip ? *

Yes

No

Admission Slip Ref No *

Admission Date *

Do you have payment Slip ? *

Yes

No

Payment Slip Ref No *

Payment Date *

Declaration

I have not availed the benefit of such scheme sponsored by the Government or any other agency in the past.
The contents mentioned in the application are correct to the best of my knowledge and belief and nothing has been concealed therein.
I undertake that the Ex-Gratia amount shall be utilized for the entire family.
I undertake to return the Ex-Gratia amount, if my declaration is proved to be wrong and liable for all Civil/ Criminal action in case of any wrong declaration.

I Agree *

Additional Details

Applied to the Office*

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