HOUSE HOLD SURVEY FORM

Sl.No GP
District: VILLAGE
Block NGO: SEWAK

Name of the HH

Contact No

GENERAL INFORMATION

AGE EDUCATION Reason of discontinuation

(if)

Whether literate(Y/N) Marital Status(Y/N) SEX

Aadhar Card No NFS Card No

Job Card No

Total Family Member ADULT CHILD MALE FEMALE

House site with patta (Y/N) Backyard/Baddi with patta (Y/N)

Recipient of IAY/Mo Kudia/PMAY (Y/N) HOUSE TYPE Wall Type

Roof Type No of Rooms Separate Kitchen (Y/S) VARENDA

Separate for Livestock IHL Presence of Toilet(Y/N) Whether using it

Water Facility(Y/N) Source of drinking water

Distance of Drinking water (Km) SOURCE OF LIGHT

Electrified Solar Firewood Others (Specify)
Distance to collect firewood (Km)

Cultivated Land (in acres)

Revenue Revenue land FRA Land FRA Land Badddi or
Patta Land without patta with patta with patta Backyard

Land Use (Acres)

Cereals Pulses Oilseeds Others Horticulture Kitchen Mortgaged
Garden
 Season wise Cultivation

Kharif Rabi Summer

Seasons Area Seasons Area Seasons Area

KHARIF
Name of the Crop Area in acer Output in Seed (local or Compost/Manure Fertilizer
Kg improved) used, Quantity used, Kg

RABI
Name of the Crop Area in acer Output in Seed (local or Compost/Manure Fertilizer
Kg improved) used, Quantity used, Kg

SUMMER
Name of the Crop Area in acer Output in Seed (local or Compost/Manure Fertilizer
Kg improved) used, Quantity used, Kg

Total Land LIVESTOCK(in Numbers)

Area under Unused Cows Buffaloes Bullock Sheep Goat Pigs Hen Other
Cultivation area
(Acre)

SOURCE WISE INCOME

NTFP Collection
Quantity Qty. for own use Qty. Sold Income Rs Buyer Person Days within
Name of Collected state
NTFP

MIGRATION
Days Nature of work Income( Days Nature of work Income
Person within Rs/Year) outside (Rs/Year)
state state
Local Wage Work Formal Employment(if any)
Person Days Nature Income Name Where Work Migrated/ Income
of (Rs/ (Govt/ (Skilled/ Communiti (Rs/
work Year) Private) Unskilled) es Year)

Non-Farm Activity(Business or Enterprise, NTFP)

Person Nature Days/Year Income Where sold
of work (Rs/Year)

TOTAL INCOME (YEARLY) –HOUSEHOLD INCOME

Agriculture NTFP Livestock Wage Wages Artisanal Salaries Other Total
(Rs) (Rs) (Rs) (Local) (Migration) (Rs) Job (Rs) Income
(Rs) (Rs) (Rs) (Rs)

EXPENDITURE DETAILS (LAST 12 MONTHS) (RS)

Food Clothing Medical Schooling/ Agriculture Festival/ Alcohol/ Others Total
Education Social Tobacco (Specify)
Function

FOOD SECURITY STATUS

Food security from own Food sources from PDS Food Scarcity ( Month if)
Produce (Month) (Month)

INDEBTNESS: SHG/BANK/TRADERS/MONEY LENDERS/RELATIVES

Relatives/Friends
Amount Purpose Period, Interest Mortgage
Month
SHG

Amount Purpose Period, Interest Mortgage

Month

BANK

Amount Purpose Period, Interest Mortgage

Month

TRADERS

Amount Purpose Period, Interest Mortgage

Month

PURE MONEY LENDER

Amount Purpose Period, Interest Mortgage

Month

Other Financial Institutions

Amount Purpose Period, Interest Mortgage Remarks(if any)

Month

Remarks of Surveyor

Signature_________________________

Name of Surveyor

Mobile No: