CIVIL SUPPLIES
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New Ration Card Form

Declaration Form No :			Reg No:
Fair Price Shop No :			Regd.No :

Declaration

I	Mr Mrs Miss	First Name:		Last Name:
	resident of:
do here by certify that the given members of the family and I are living in the same household at the address and I solemnly affirm that the details given are true and correct.

S.No	Name of the Members of the family including the head of the family living in the same house	Age	Relationship	Profession	Annual Income
1.
2.
3.
4.
5.
6.

Full Address :
Other Source Of Income if any :
Total Annual Income :

NOTE: The Person giving this declaration should know that the supply card that would be issued to him is liable for immediate cancellation and he is liable for prosecution under the Essential Commodities Act,1955 in case any informaton furnished herein by him is false or proved to be false at a later stage.

     

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