Empower

Empower Your Family with SSEG

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Choose State

Choose District

Choose City/Town

Ward Name

Ward Number

Block

Gram Panchayat

Village

Address

Mobile* (Head of Household, if not any other active member of the family)

Email Address*

Status of House

No of Rooms

Whether have toilet

Whether have LPG Gas Connection

Household Income

Name	Sex	Relation with Head of family	Date of Birth	Educational Education	Activity Status	Specify Activity Engaged in	Mobile No

Note: In case, any member of your family possess unique/special human resource potential/ skill/ talent/ knowledge/ interest/ social service aptitude /voluntarism etc., pl. provide specific information so that his/her skill could be pooled and channelized to benefit the most. If space is less for household, detailed information may be written on back of the sheet by mentioning sr. no. of household.