National Food Security Act ... - Ration Card Agent · Application form for obtaining New Ration Card under the National Food Security Act. To The Civil Supplies Officer, Civil Supplies

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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