al Annexure -T Under rule 31(vitiy and rule 2)(2) sig AMULY- IDENTITY CARDRATION CARD DATA ENTRY FOR ant Head of the Family for sue of new Family Mente Card / Rati |. PARTICULARS OF THE HEAD OF THE FAMILY: ‘+ Name of Head of Family :... © Mother’s Name :.. © Father's Name © Spouse Name : * Gender... Date of Birth (dd/mm/yyyy) : eee age ‘© Nationality Caste. 7 ‘© Landline phone No... +. Mobile No (for SMS Alert Bank Name & Branch t...s00 © Bank A/CNo. .. © Job Card No: ‘© BPLSLNo. (for BPL Applicant) 1 (a) PRESENT ADDRESS; © State: . * District : © Sub- Division: .. * Circle: © Rural /Urban Flag (R/U) : * Block © GP/Town: + Village! Ward... ‘e Status of Residence Owner House /Rent House ‘© Name of House Owner (for rented house): . *PIN: ‘© Landmark/Locality/Colony : Scanned with CamScannerfame dot! Eat St 10) VATA (asper Voter's ist *# Lok Sabha Constituency (HPC): + Assembly Constituency (LAC) # Year of Votes Liss + No, of Polling Station * Serial No. under polling Station (as per Voters List): 146) PERMANENT ADRESS :- (If present address & Permanent address are same, Tick( # Stat en * Sub- Division: * Rural / Urban co + GP/Town Committe: *Landmazi/Locality/Colony 2.PROFESSIONAL DETAILS =~ * Total Annual Income : 3. AADHAAR CARD DETAILS :- (family head) * Aadhaar Card No: + Aadhaar Card link Mobile No. 4. LP. GAS CONNECTION DETAILS = + Gas Connection Status (Available/Not Available) + "Gas Company Name: * Gas Agency Name * Consumer Number + Name of Polling Station : 1 District: _* House No, (as per Voter's List): ) (VESINO) * Circle: * block: soot Village! Ward PIN: a Scanned with CamScanner5 Detailed particulars about place of birth of the applicant * States * Distriet, + Sub-Division: * Circle + Rural/Urban Flag (R/U) .... * Block * Village! Word £ ....sseeceeeeeees + GPTown VCD! «. : + Since when the applicant is residing in his present address mentioned in paragraph — (above . (Please specify the year) uments required to be enclosed along with this form : 1 6 1. Detailed particulars of family members in Annexure 2. Copy of Aauhaar of All members, 3. Copies of birth certificates of minor members (Below 10 years in age) 4, Photocopy of Bank Passbook of Head of the Family 5. Certified copy of relevant page of Voter's list 2008 6. Copy of tax pay /Land Revenue pay receipt Identity Card of non 7. Surrender Certificate of Ration Card /Family Availability Certificate from the FCS&CA authority where the applicant was previously resided. 8. Address Proof (attested copy of PAN card /Driving License /Bank Passbook 1 / Electricity Bill/ Telephone Bill) /Post Office Passbook/Municipal Holding re 1, Shri/ Shrimati......sssesse vee : aoe Pertenece (name of the head of the family) declare that the particulars of my self furnished here in above ‘nd also of my family members given in Annexure -1 attached 10 this declaration, are true and correct and nothing has been concealed there in. I have carefully gone through the provisions ‘order 1982 and also the provisions of the Public of the Assam Publie Distribution of Articles Distribution System (Control) Order 2001 made by the State and Central Government respectively under section 3 read with section 5 ofthe Essential Commodities Act 1955(Act 10 of 1955). I shall be held responsible for furnishing the above information if it is false in any material is reasonable cause to believe it to be false, or is not believed to be true jority as defined in the aforesaid ‘Control Orders’ and will th section -9 of the Essential particular and if there by the Licensing Authority or Auth thereby be liable for prosecution under Section -7 read wit Date ( Signature in full of the Head of the Family) Scanned with CamScannercae a 3 pe Scanned with CamScannerJf ANNEXURE-I ACKNOWLEDGEMENT Received the declaration made in FAMIL CARD DATA ENTRY FORM dl sri/Smt IDENTITY CARD/ RATION filed in by paste Photograph of Head of Family In Form Serial No For issue of a new FAMILY IDENTITY follow’ rlosed alonewit Documents required to be 1. Detailed particulars of family members in 2. Copy of Aadhaar ofall members m Copies of birth certificates of minor Photocopy’of Bank Passbook of Head of F Certified eopy of relevant page of V 6. Copy of tx pay /Iand revenie pay Fes 47, Surrender Ceatticate of Ration Card! Fam ron availability cert applicant was previously resided «J copy of PAN Cart 8, Address proof (attest Post Of itieate from the FCS&CA authori ice Passbook! Municipal CARD/ RATION CARD together ‘ ) box Iv this form Tick ( Annexure vers (below 10 years) ily Ldentity holding oF ty where the Driving License! Holding Receipt! Authority Seal & signature of Recipient Scanned with CamScanner4 J Criterta for seloction of b Yojona(AA’ cana onolciaries , households under Antyodaya Anna Yojons(AAY) MeGOTy 18 por Elauso(a) of sub-section(t) of section 10 of tho Act ehall bo 8 follows: {0} Momaiees nousonolds and ne nousenaldswiout shal. (b)Patents sutfering from cancer and HIV patients irrespectve of his income. {9} aea5 twanssendor porson with dsabity as dened Inthe Right of parson wih 2 : ‘wig persons resiaing in old age homes. (6) (22688 93 twat abouts, magna famers ual atsns, ramen, pone aioe blaesinin carpenters, masons. ()teaanden nardon workers (9) All casuah workers. divers, conductors, handymen, porters. 1, batt coubiers, sweepers, electrioans colivory nen, nekshaw pullers, nandeart pulls, ful, vegetable, fish and fewer vendors seting on pavements oe ‘awrles provided that her total family income is less than Rs. 2.50 ansnsok noome Blow Rs 2 50 Lakhs provided thatthe above teria is cedhpustve (em) Crug noaged nousehets (a): t.6 ean members ofthe household are either eisabled chronically i, or aged ean valy years of age fo) Soyr sora" ncluding wioows, uomerieg and separated and deserted woman) e>sla 18 depencent aie vy ins (1A for tae Heal nousene (2) Tho exclusion paramoter for prlatty househo) ExtLas (oe +c zan.ane roles Government servants drawing pensions more then, on eee vencles ‘or than smatt and marginal Categories. 0 ‘Aveniects Chartered Accountants, Bark Ottis, Lawyers . orto une supple, roa estate bude, industiaiss, trade teense colge, Higher Sacondary, Junior Cotog, High School, Upper LP Provhwiazted) wachers ho pay income taxa persons whose fay income Is more 0 Loans per arn itera and indicative and not exhaustive, Scanned with CamScanner