national food security act ... - ration card agent · application form for obtaining new ration...
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Office of the Collector/Secretary, Food and Civil Supplies Department,
Daman & Diu.
Application form for obtaining New Ration Card under theNational Food Security Act.
To
The Civil Supplies Officer,
Civil Supplies Department,Collectorate,
Daman /Diu.
Photo
1. Name of the applicant(Eldest women of the family)
2. Existing Ration Cards No.Category (APL, BPL, AAY)
(Produce the Old Ration Card)
3 (a) Residential Address(Attach proof)
(b) Mobile No ./Alternate Contact No. .
4. Name of the Family Members. :
Sr.No.
Name of the Family Members Age Relation Sanjivani SwasthyaBima Yojana
Card No.
Aadhar No. /NPR No.
1
2
3
4
5
6
7
8
9
10
5. Bank Account No. Name of the Bank Branch(In the name of Eldest woman of the family)
6. House No.(As per house Registration with villagePancha at/ Municipal Corporation )
7. (a) Are you residing in rented house ? Yes No(Attach rent agreement )
(b) Are you staying in a houseallotted by company. ? (Attach Proof) Yes No
8. (a) Are you a resident of Daman/Diu ?(Attach Proof) Yes No
(b) Are you a resident of other state ? Yes NoIf yes which state ?
(c) Do you have LPG Gas Connection Yes No
(d) How many Gas Cylinders do youhave. ?
9. Are you a homeless house hold. ? Yes No
10 Are you a Single Woman ? Yes No(unmarried/ separated /deserted)
11. Do you belong to scheduled tribe or Yes Noscheduled caste. ?
(Attach Self Attested Proof)12. Are you a landless Agriculture Labour ? Yes No
13. How much Areas of land in irrigated/command area do you own in the U. T.of Daman & Diu.
(Attach form 1 & XIV)14. How much Areas of land do you own in
Non irrigated/ Non command are in the
U.T. of Daman & Diu.15. Are you registered as organized Labour
under the provision of the unorganized Yes Noworkers Social Security Act-2008 (33 of2008).(Attach Proof)
16. Under which category do you fall Rag Fishermen Unskilled Porters(Please Tick Mark) Pickers Construction
WorkersCasual Casual Cycle Unskilleddaily domestic rickshaw workerswages laborers driverslabourersSmall Enterprise/ Household Sweepers/household unskilled industries Sanitation
workers workersDisabledpersons
17. Are you a Transgender. ? Yes No
18. Are you living in a Kutcha House ? Yes No
19. What is your Annual Income ?(Produce income certificate) Rs. /-
20. Are you paying Income Tax ? Yes No
21. Does any member of your family owns alight motor vehicle or heavy vehicle ? (If
yes, give its details and the purpose of Yes Nouse of vehicles) Private or Commercial.
22. Are you a Government Employee ? Grade Pay Rs.(1) If yes please specify the Grade Pay
and Group of Post. (A.B. or C) Yes No Group of Post.
23. Are you a Employee of any Board/ Grade Pay Rs.Corporation/ Enterprises/undertaking/Other autonomous bodies/ Authoritiessuch as college, Municipal council etc. ? Yes No Group of Post.(1) If yes above please specify group ofpost (A.B. or C) and grade pay, monthlysalary. Grade pay Monthly
Rs.
Monthly SalaryRs.
Place :
Date: (Signature of the Applicant)
DECLARATION
I the undersigned Shri/Smt a resident
of aged about occupation a citizen of India do
hereby solemnly affirm & declare that I have gone through the inclusion and exclusion criteria prescribed
Vide Notification No. 1/113/CSD/DMN/NFSA/2013-14/4825 dated 10/02/2014 for the issue of Ration
Card under National Food Security Act, 2013. 1 declare that I qualify for both inclusion and exclusion
criteria. Therefore, I am eligible to obtain Ration Card under National Food Security Act, 2013. I do not
possess or I have not applied for new Ration Card elsewhere under National Food Security Act.2013.
I know that to make any false declaration is an offence and liable for penalty and cancellation of
Ration Card.
(Signature of the Applicant)
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