Schedule-C FORM RO. 1 (Clause-4) Government of West Bengal Application for Ration Card Applicants name .... vm Address : Name of the Head of the family . Si. Name ofthe [Age [Relationship] “Name offather/ | Occupation | Whether [Immediate] Reason fornon- | EP Shop No. |member for whom] with the | husband! parents Indian | previous | possession of R/ | No. desired Ration Card is Head of | (incase of mantied Citizen | “address | Card (im absence required family woman) (ifany) | of Surrender Certificate) 1 2 3 4 5 6 7 8 9 1 1. Proofof Residence: Municipal/Panchayat Tax Receip/Rent Receipt’ | 1 solemnly afliem that Electric Bill/Telephone Bill/Certificate from local elected | the above statements Documents to be Representative for completely new Ration Cards ofall the members | are truc to my knowl- attached ‘of family or Ration cards against surrender certificate edge and belief, eens 2. Proof of Age : Birth Registration Certificate /School Certificate! a ‘any authorised document indicating the age of members. Possessin/Non-possession Certificate: Surrender Certificate along ‘with cancelled Ration Cards indicating possession of Ration Card/ certificate by a member from the elected representative ofthe locality ‘where the person previously resided. Proof of Citizenship: EPIC of self, parents or grand parents/Passport! Electoral Roll/Employment Exchange Registration Card/any Govt. Licenee/any other relied document which only an Indian Citizen can have. Receipt SiNo. Returnable Date: & Date Signature of the Receiving Official