Name of Assembly
-- Select Assembly --
Name of Beneficiary
Mobile/ Tel. No
Do you have an existing toilet facility in your house?
[If yes, how many existing superstructures will be connected to the toilet facility?
How many rooms do you have in your house?
How many people are going to use the toilet facility (including children)?
How many of the users are above 60 years or are physically challenged?
Do you have pipe borne water from GWCL in your house?
Is your compound waterlogged? (please explain what waterlogged means to the beneficiary)
Does your compound floods when it rains?
Do you have constructed drains within 10m radius from your house?
Confirm and Pay