ANNEXURE “H”
DECLARATION
(See clause 7 (1) of G.D.D. Controlled Commodities (Regulation of Distribution Order 1966)
Taluka _____________ Panchayat Municipality ________________village_________
Word Wado ______________ *H.No._____________ Old Ration Card No.________
other evidences
F.P. Shop No. ________________ Kerosene Dealer ___________________________
Name of the Head of the Family ( in full )___________________________________
Name of the persons
in the family
including Head of
the family
Relation to the Head
of the family
Age IC.No.
2.Total number of persons __________(Children (upto age 5) ) _________________
( Adults ( from 5 onwards) ) ____________
3.What is the stock held by the Head of the Family or any member of the family:-
( Paddy _________________ quintals)
(Rice ____________________________ quintals )
4. Total monthly income of all members of the family ______________Rs._________
5.Whether the house is electrified or not ____________________________________
6.No. of L.P. Gas connection in the family _____________________________________
Name of the Agent Consumer No.s
_______________________ _______________________
_______________________ _______________________
_______________________ _______________________
_______________________ _______________________
7. I do solemnly declare that :-
i) I or any of the above mentioned member of the family do not possess ration card in my/their names nor my/their name/names is/ are included in the ration card elsewhere.
ii) The above statement is complete and true to the best of my knowledge and belief and I undertake to hold myself responsible if any part or whole thereof is found to be false.
Place:- ________________
Date:- _________________
Signature/Thumb impression of the Head of the Family.
Please mention H.No. given by Panchayat/Municipality or name of the Building/Flat No.
Mention correct name and ages as per Birth Certificate.
The declaration should be signed by the Head of the Family only.
FOR OFFICE USE ONLY
Card No. allotted ____________ Sr.No. of Declaration _________________________
Name of F.P.Shop Owner/Society _______________________ No._______________
Name of the Kerosene Retail Dealer ________________Location________________
DETAILS OF CHANGES :-
Date Addition Deletions Surrender Reasons
for
duplicate
R.C.
Change
of
F.P.Shop
Remarks Initials
Ch Ad Ch Ad Ch