Office of the Collector/Secretary, Food and Civil Supplies Department,

Daman & Diu.

Application form for obtaining New Ration Card under the

National Food Security Act.
To
The Civil Supplies Officer,
Civil Supplies Department,
Collectorate,

Photo

Da man /Diu.

1.

Name of the applicant

(Eldest women of the family)

2.

Existing Ration Cards No.

Category (APL, BPL, AAY)
(Produce the Old Ration Card)
(a) Residential Address
(Attach proof)

(b) Mobile No ./Alternate Contact No.

4. Name of the Family Members. :

Sr.
No.

Name of the Family Members

Age

Relation

Sanjivani Swasthya
Bima Yojana
Card No.

1
2
3
4
5

6
7

8
9
10

5. Bank Account No. Name of the Bank Branch

(In the name of Eldest woman of the family)
6.

7.

8.

House No.
(As per house Registration with village
Pancha at/ Municipal Corporation )
(a) Are you residing in rented house ?
(Attach rent agreement )
(b) Are you staying in a house
allotted by company. ? (Attach Proof)
(a) Are you a resident of Daman/Diu ?
(Attach Proof)
(b) Are you a resident of other state ?
If yes which state ?
(c) Do you have LPG Gas Connection
(d) How many Gas Cylinders do you
have. ?

Yes

No

Yes

No

Yes
Yes

No
No

Yes

No

Aadhar No. /
NPR No.

9.

Are you a homeless house hold. ?

Yes

No

10

Are you a Single Woman ?

Yes

No

Yes

No

Yes

No

(unmarried/ separated /deserted)

11.

12.
13.

Do you belong to scheduled tribe or

scheduled caste. ?

(Attach Self Attested Proof)

Are you a landless Agriculture Labour ?
How much Areas of land in irrigated/
command area do you own in the U. T.
of Daman & Diu.

(Attach form 1 & XIV)

14.

How much Areas of land do you own in

Non irrigated/ Non command are in the

15.

Are you registered as organized Labour

under the provision of the unorganized
workers Social Security Act-2008 (33 of

U.T. of Daman & Diu.

Yes

No

2008).(Attach Proof)
16.

Under which category do you fall

(Please Tick Mark)

17.

Are you a Transgender. ?

18.

Are you living in a Kutcha House ?

19.

What is your Annual Income ?

(Produce income certificate)

20.

Are you paying Income Tax ?

21.

Does any member of your family owns a

light motor vehicle or heavy vehicle ? (If
yes, give its details and the purpose of
use of vehicles) Private or Commercial.
Are you a Government Employee ?
(1) If yes please specify the Grade Pay
and Group of Post. (A.B. or C)

22.

23.

Are you a Employee of any Board/

Corporation/ Enterprises/undertaking/
Other autonomous bodies/ Authorities
such as college, Municipal council etc. ?
(1) If yes above please specify group of
post (A.B. or C) and grade pay, monthly
salary.

Rag
Pickers

Fishermen

Casual
daily
wages
labourers
Small
household

Casual
domestic
laborers
Enterprise/
unskilled
workers

Disabled
persons
Yes
Yes

Unskilled
Construction
Workers
Cycle
rickshaw
drivers
Household
industries

Unskilled
workers

Sweepers/
Sanitation
workers

No
No

Rs. /Yes

No

Yes

No
Grade Pay Rs.

Yes

No

Group of Post.
Grade Pay Rs.

Yes

No

Group of Post.

Grade pay Monthly

Rs.
Monthly Salary
Rs.

Place :

Date:

Porters

( Signature of the Applicant)

DECLARATION

I the undersigned Shri/Smt a resident

of aged about occupation a citizen of India do
hereby solemnly affirm & declare that I have gone through the inclusion and exclusion criteria prescribed
Vide Notification No. 1/113/CSD/DMN/NFSA/2013-14/4825 dated 10/02/2014 for the issue of Ration
Card under National Food Security Act, 2013. 1 declare that I qualify for both inclusion and exclusion
criteria. Therefore, I am eligible to obtain Ration Card under National Food Security Act, 2013. I do not
possess or I have not applied for new Ration Card elsewhere under National Food Security Act.2013.

I know that to make any false declaration is an offence and liable for penalty and cancellation of
Ration Card.

(Signature of the Applicant)

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