MANDAL PRAJA PARISHAD POLAVARAM

Rollback Request Form

Date

Grievance Serial No

Name Of The Pensioner

Pension Id

Father/Husband Name

Ration Card Number

Aadhaar Card Number

Type Of The Pension

OAP
WIDOW
DISABLED

Problem

Why was it is deleted

Why now it is proposed again

Who is responsible for that mistake

What action has been taken on them

Phone

Date:

Grievance Serial NUmber

Name of the Applicant

Father/Husband Name

House no & Address:

RATION CARD NUMBER

AADHAR CARD NUMBER

SADAREM ID

Gender

Age

Caste

Required Pension

OAP
WIDOW
DISABLED
ART
TODDY TAPPERS
WEAVERS

Phone

REMARKS