4292 THE ASSAM GAZETTE, EXTRAORDINARY, JUNE 02, 2022
Annexure - I
FORM - C
Under rule 3(1) (viii) and rule 5(2)(a)
FAMILY IDENTITY CARD / RATION CARD DATA ENTRY FORM
(EXISTING CARD HOLDER / NEW APPLICANT) Please tick (ü) (to be given by local office)
Declaration of Head of the Family of existing Family Identity Card / Ration Card holders for fresh verification
Declaration of Applicant Head of the Family for issue of new Family Identity Card / Ration Card
(See clause-2(d) of the Assam Public Distributor of Articles Order, 1982 AND clause - 2(m) read with paragraph - 2
of clause - 4 of the Public Distribution System (Control) Order, 2001)
(All Fields marked with a star are mandatory fields and MUST be filled)
* Card Type : (APL / BPL / AAY / MMASY) Paste
Photograph
* Card No. (Applicable for existing card holders) : of Head of
Family
1. 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) : * Age :
* Nationality :
* Landline phone No. : * Mobile No. (for SMS Alerts) :
* Bank A/C No. : * Bank Name & Branch :
* Job Card No. :
* BPL Sl. No. (for BPL Applicants) :
1.(a) PRESENT ADDRESS :
* State : * District :
* Sub-Division : * Circle :
* Rural / Urban Flag (R/U) : * Block :
* GP / Town / VCDC : * Village / Ward :
* Status of Residence - Own House / Rented House :
* Name of House Owner (for rented house) :
* Landmark / Locality / Colony : * PIN :
* Census House No. :
THE ASSAM GAZETTE, EXTRAORDINARY, JUNE 02, 2022 4293
1. (b) ELECTION DATA (as per Voter’s List) :
* Lok Sabha Constituency (HPC) :
* Assembly Constituency (LAC) :
* Year of Voter’s List :
* No. of Polling Station : * Name of Polling Station :
* Serial No. under Polling Station (as per Voter’s List) :
* House No. (As per Voter’s List) :
1. (c) PERMANENT ADDRESS : (If Present Address & Permanent address are same, Tick (ü) checkbox)
* State : * District :
* Sub-Division : * Circle :
* Rural / Urban Flag (R/U) : * Block
* GP / Town / VCDC / * Village / Ward :
* Landmark / Locality / Colony : * PIN :
2. PROFESSIONAL DETAILS :
* Occupation :
* Total Annual Income :
3. AADHAAR CARD DETAILS :
* Aadhaar Card No. :
* Aadhaar Card link Mobile No. :
4. L.P. GAS CONNECTION DETAILS :
* Gas Connection Status (Available / Not Available) :
* Gas Company Name :
* Gas Agency Name :
* Consumer Number :
5. For Existing Family Identity card / Ration Card Holders only :
(i) * Name of F.P. Shop tagged :
(ii) * By whom the existing Family Identity Card / Ration Card has been issued :
Please specify the Issuing Authority : (please mention as locam FCS&CA authority / GPSS or WCCS management)
Attached Enclousers : 1. Copy of Existing Ration Card (Tick (ü) box)
2. Detailed particulars of family members in Annexure-I
3. Copies of birth certificates of minor members
(Below 10 years in age)
4294 THE ASSAM GAZETTE, EXTRAORDINARY, JUNE 02, 2022
6. For New Family Identity Card / Ration Card Application :
(a) Detailed particulars about place of birth of the applicant
* State : * District :
* Sub-Division : * Circle :
* Rural / Urban Flad (R/U) : * Block :
* GP / Town / VCDC/ * Vilage / Ward :
* Since when the applcant is residing in his present address mentioned in paragraph - I (a) above :
(Please specify the year)
7. Documents required to be enclosed along with this form :
1. Detailed particulars of family members in Annexure-I
2. Copies of birth certificates of minor members
(Below 10 years in age)
3. Certified copy of relevant page of Voter’s list 2008
4. Copy of tax pay / land Revenue pay receipt
5. Surrender Certificate of Ration Card / Family Identity Card or non
availability certificate from the F,CS&CA authority where the
applicant was previously resided.
6. Address Proof (attested copy of PAN card / Driving License / Bank
Passbook / Post Office Passbook / Municipal Holding
receipt / Electricity Bill / Telephone Bill
I, Shri / Shrimati .........................................................................................................................................................
(name of the hear of the family) declare that the particulars of myself furnished herein above and also of my family
members given in Annexure - I attached to this declaration, are true and correct and nothing has been concealed therein.
I have carefully gone through the provisions of the Assam Public Distribution of Articles Order 1982 and also the
provisions of the Public Distribution System (Control) Order 2001 made by the State and Central Government respec-
tively under section - 3 read with section - 5 of the 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 particular and if there
is reasonable cause to believe it to be false, or is not believed to the true by the Licensing Authority as defined in the
aforesaid ‘Control Orders’ and will thereby the liable for prosecution under Section - 7 read with section - 9 of the
Essential Commodities Act, 1955 (Act 10 of 1955)
Date : (Signature in full of the Head of the Family)
THE ASSAM GAZETTE, EXTRAORDINARY, JUNE 02, 2022 4295
FAMILY IDENTITY CARD / RATION CARD DATA ENTRY FORM
Annexure - I
* Card Type : * Card No. (Application for existing card holders) :
(APL/BPL/AAY/MMASY)
* For New Applicant (Places tick ü) :
Family details including Head of Family : Form Serial Number :
(Fields marked with a star are mandatory firlds and MUST be filled) (Same as mentioned in the Declaration form attached herewith)
Sl. Paste Name of the Aadhaar Gender Date of Age Voter Father’s Mother’s Spouce Relation Nation- Opting to
No. Photograph * family Card No. Male / Birth Serial Name * Name * Name skip ality * ......
members * Female * DD/MM/ No. (for (Lt/ with commo-
YYYY * adult Husband/ Applicant dity
members Wife * (Y/N) *
only) *
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* Attach more sheets if required for family details.
Date : (Signature in full of the Head of the Family)
4296 THE ASSAM GAZETTE, EXTRAORDINARY, JUNE 02, 2022
FAMILY IDENTITY CARD / RATION CARD DATA ENTRY FORM
Annexure - II
ACKNOWLEDGEMENT Paste
Photograph of
Head of
Received the declaration made in FAMILY IDENTITY CARD / RATION CARD DATA ENTRY Family
FORM duly filled in by Shri / Shrimati ..................................................................................................
In form Serial Number :
A. For existing cards, Card No. : Card Type :
(APL/BPL/AAY/MMASY)
Documents required to be enclosed along with this form : (Tick (ü) box)
1. Copy of Existing Ration Card
2. Detailed particulars of family members in Annexure - I
3. Copies of birth certificates of minor members
3. (below 10 years in age)
B. For issue of a new FAMILY IDENTITY CARD / RATION CARD) together with copies of following Documents :
Documents required to be enclosed along with this form : (Tick (ü) box)
1. Detailed particulars of family members in Annexure - I
2. Copies of birth certificates of minor members
(Below 10 years in age)
3. Certified copy of relevant page of Voter list
4. Copy of tax pay / land Revenue pay receipt
5. Surrender Certificate of Ration card / Family Identiry
holding or non availability certificate from the F,CS&CA
authority where the applicant was previously resided.
6. Address Proof (attested copy of PAN card / Driving
License / Bank Passbook / Post Office Passbook /
Municipal Holding receipt / Electricity Bill /
Telephone Bill)
Receipt No. :
Date of Receipt :
(Seal and Signature of Recipient Authority)
B. R. SAMAL,
Additional Chief Secretary to the Government of Assam,
Food, Civil Supplies & Consumer Affairs Department.
