44 Ward No. Corporation /Municipality Enumeration Block Address - Mobile No. (of any family member) If Ration Card is possessed/held at present, please mention present Ration Card no., Folio no., Name & No. of the Ration Shop** and Type of Ration Card (APL/BPL/AAY)** AHL TIN** Name of the Members of Family Father’s Name Mother’s Name Gender EPIC no. or Aadhaar no. Relation with Head of the Family (in case of Head of the family, please mention as “Head”) Date of Birth / Age (as on 1 st January of current year) Reason(s) for inclusion (please mention the appropriate sl no. of Deprivation. Index (s) as noted on the reverse side) *Please write the name of the Ration Shop and Number in the first column. In case of other members of the family mention Ration Card no., Folio no., name of the Ration Shop** and no., type of Ration Card * * AHL TIN. I do hereby also declare and affirm that – (1) The auto exclusion ……………………………..indices as referred on the reverse page is/are applicable in case of my family (write the Sl. No. of the Depreciation Index) / (2) None is applicable. [Please strike out which is not inapplicable between (1) & (2)] ________________ Signature of Applicant ---------------------------------Return this portion to the Applicant------------------------- The application form III-U (for inclusion in the NFSA/RKSY eligible Family List) has been received from Shri / Smt………… Address…………………………………………, Ward no…………………. __________________ Signature of Authority(with Seal) [see overleaf]