61 Village Samsad - Village - Mouza – Mobile no. (of any family member) - *If surrender application submitted due to death of any family member, please mention date of death. Submission of death registration certificate is mandatory. ------------------------------Return this portion to the Applicant---------------------------- The application form VII-R for Exclusion of name(s) from NFSA/RKSY Eligible beneficiaries’ List has been received from Shri / Smt………………… ……………………., Address…………………………………………, Village…………………. Signature of Authority (with Seal) #Reason for Surrender – (1) Death of family member (2) Other reasons. GOVERNMENT OF WEST BENGAL FORM 3 Application for replacement of mutilated/defaced or lost Ration Card [Vide clause 13 of the WBPDS (M&C) Order, 2013) Applicant's Name...................................................................................................................................... Address: House No................................................................ Flat No....................... Ward No.............. Street/Road/Lane.. ............................................................. Para .................................. Village/Municipality............................................................................... Post ..................... P.S. .................................................. Name of Head of family...............: SI. No. Name of the family member for whom Ration Card is to be replaced Age Relationship with the head of the family Name of father/ husband NFSA/RKS Y card no Card type (AAY/PHH/SPHH/ RKSY-I/RKSY-II etc.) Name of Head of the Family Name of the other family member of the family who possesses the card of NFSA / RKSY State reason for exclusion from the NFSA/RKSY list *#