GOVERNUENT OF TAMILNADU DEPARTTENT PROTECTION ANDCONSUMER CIVILSUPPLIES FATUIILY CARD FOR PROOF.OF.

RESIDENCE APPLICATION
ZONE/TALUK

No (Computergenerated) Applicatircn

(or) Signature Thumblmpression of Applicant Note: Application shouldbe filledup in blackink

Passport size photo of Head of Family 5cmx3cm

Name 2.Fathe/s/ Husband's

{ame(English) 3. a. Full Address: b. Year from which llvlng In thls address:

Telephone:

Mobile:

(writeheadof bmily first): 4. Detailsof familymembers :lectionPhoto Uonthly IncomdentityCard Nationality Relationship Profession (ln tlumber Rs.) 'lf above18vears)

il.Nc

Name

Date of birth )el

2 3
4

5
6 7 I 9

10
Applicants are advisedto collectan acknowledgement slip with serialnumberafter submission of application in the Taluk or Zonal office.Accepted applications with necessary documentsas abovewill be approvedby TSO or AC concernedand card deliveredwithin 7 days of applicationreceivedby RPAD/Courier

5 Proof of resldence: Enclosecopy of any one documentbelowas proofof residence (Applicant's name and addressmustappearin the document) Pleasetick (
1

Document lD No.

/oter ldentityCard )ass Port :ront pageof Bank Passbook vledical Insurance ldentity Card )rivinqLicence dobile/ Landline Bill

2
3
4

5 6

6. Certificate: ll certifuthat I and my familymemberslistedin this application are indiancitizens.I also cerifythat me or membersof my family listedabove do not find place in any famity/ration cards issuedby any State Govemment in India. The above particulars are true to my knowledge. lf it comesto noticeat a laterdate that particulars given by me are eitherwrong or contraryto truth, I am awarethat the proof-of- residence familycard issuedto me will be cancelled and actionpursuedagainstme underEssential Commodities Act (Act 10 of Central Act),1955. I am awarethat Proofof residence familycardcannotbe converted intoa regular familycard in future.I am awarethat I shallhaveto pay Rs.100 alongwiththis application form and this amount will not be refunded is foundineligible. if the application Place: Date: (For office use only) 3r9otel6 uerftig rougrir )istrict Code l-aluk Code )lace Code \rea Code /VardCode jhop Code itreet Code >inCode )istrict Headquarter ? -PG: )ilCompanl 3ylinders )ealer lard Option:PROOF-OF-RESIDENCE FAMILY CARD ncome(Monthly) :ategory )ld FamilvCard No:
3ivil l/es

Signature of Headof Family

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LocalBodyName

LocalBodyGrade: lP ITP / Mplty/ Corporation

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