Schedule 1
(Relating to sub-rule (1) of Rule 8, sub-rule (3) of Rule 12 and sub-rule (3) of
Rule 16)
Personal Records of Senior Citizen
1. Personal Details of the Senior Citizen:
(a) Name and surname of senior citizen:
(b) Name of father and mother:
(c) Name of grandfather and grandmother:
(d) Date of birth and place:
(e) Address:
(i) Permanent address: District: ………….. VDC/Municipality:
………………… Ward No. ………………….. Tole/Village:
………………….. Phone: …………………. Email:
………………….
(ii) Temporary address:
(b) Sex:
(c) Details relating to health (to be mentioned special disease,
physical disability or long term disease if any): …..
(d) Citizenship:
2. Details relating to the family of senior citizen:
(c) Of the son, daughter-in-law, daughter, grandson and
granddaughter of joint family.
(e) Name, surname and address:
(ii) Details relating to property and income:
(d) Of the son, daughter-in-law, daughter, grandson and
granddaughter that is separated.
(i) Name, surname and address:
(ii) Details relating to property and income:

(e) Details relating to the successor:

d. Other family background:
3. Academic qualification and professional skill of the senior citizen:
(a) Academic qualification:
(b) Professional skill:
(c) Sector of experience:
4. Details of property of the senior citizen:
(a) Movable property:
(b) Fixed property:
Certifying official:
Name and surname:
Post:
Agency: