Office of the Collector/Secretary, Food and Civil Supplies Department, Daman & Diu. Application form for obtaining New Ration Card under the National Food Security Act. To The Civil Supplies Officer, Civil Supplies Department, Collectorate, Da man /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 Swasthya Bima 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 village Pancha at/ Municipal Corporation ) 7. (a) Are you residing in rented house ? Yes No (Attach rent agreement ) (b) Are you staying in a house allotted 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 No If yes which state ? (c) Do you have LPG Gas Connection Yes No (d) How many Gas Cylinders do you have. ?
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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)
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