Please attach Recent Photograph

House owner’s name:
Address: Mobile No.:
Number of family members: a) Male b) Female c) Children
d) Older/ Disabled: e) Total:
Main income source with its types:
Agriculture Type: Business Type: Service Type: Others
Number of family members employed:
Damages caused by earthquake:
a. No. of family members death:
b. No. of family members injured:
c. House Condition: Needs to be maintained Needs to be rebuilt
When was it built?
Type of structure:
Mud and brick based building Concrete wall based building
Number of storey: Number of rooms:
Number of pet animals:
Cows: Buffalo: Hen: Bird: Others:
Relief expectation:
Construction Temporary House Health Food Water Clothing Others
Current situation of daily lifestyle:
a. Accommodation: Good Average A bit difficult Difficult
b. Food management: Good Average A bit difficult Difficult
c. Have you received relief materials? Yes No
d. Are you living outdoors? Yes No
e. Can you construct the building by yourself? Yes No