Beneficiary Verification Form

Complete all sections to verify your eligibility for support

Need Assessment

Tell us about your situation

Why are you applying for this support?*

What will happen if you do NOT receive this help?*

How will this support change your future?*

Have you received help from any NGO/Trust before?*

Type of Support Needed

Select the category of assistance

Support Category*

Estimated Cost/Support Needed (₹)*

Detailed Description of Need*

Personal Information

Your basic details

Full Name (as per government ID)*

Gender*

Date of Birth*

Mobile Number*

Alternate Contact Number

Email ID

Aadhaar Number*

Upload Aadhaar (Front & Back)*

Recent Passport Size Photo*

Family Background

Family and household information

Father's Name*

Father's Occupation*

Father's Monthly Income (₹)*

Mother's Name*

Mother's Occupation*

Mother's Monthly Income (₹)*

Total Family Members*

Number of Earning Members*

Number of Dependent Members*

Living Conditions

Residential details

Full Residential Address*

Type of House*

Number of Rooms*

House Ownership*

Access to Electricity*

Access to Clean Drinking Water*

Access to Toilet Facility*

Upload House Photos (Front, Living Area, Kitchen)*

Financial Status

Income and financial details

Total Monthly Household Income (₹)*

Primary Source of Income*

BPL Card*

Ration Card Type*

Outstanding Loans*

Bank Account Holder Name*

Bank Name*

IFSC Code*

Account Number*

Education Details

For education-related support (if applicable)

Current Education Level

Name of School/College

Type of Institution

Last Exam Percentage/Grade

Upload Last Marksheet

Career Goal / Future Ambition

Medical Details

For healthcare-related support (if applicable)

Patient Name

Relationship to Patient

Hospital Name

Doctor's Name

Medical Condition / Diagnosis

Estimated Treatment Cost (₹)

Upload Medical Reports

Verification & Declaration

Final verification

Upload Live Selfie*

Short Video Explaining Situation (30 seconds)

Declaration

I confirm all information provided is true and accurateI agree to verification visits/calls from the LeaveALegacy teamI agree that my data may be shared with donors for transparency purposes

Our team will verify your application within 5-7 business days and may contact you for additional information