FARM NO.3 Sl.No........... Date of Receipt....... Registration No....... APPLICATION FOR CHANGE IN THE FOOD CARDS Warning :- It is an offence punishable with imprisonment and/or fine to make false statement in this application. i) Change in Age ii) Change of address within Circle 1. Name of the Head of Family................ iii) Change of H.O.F. iv) Change of F.P.S. 2. Present Address..................... v) Change in mode of drawal vi) Change of category 3. (a) Food Card No...... vii) For correction of inaccuracy in (b) F.P.S. No......... Units as on card the Food Card. Cereals.......... (c) Registration No...... Sugar.......... Note:- Information against item No.1 to 3 is to be given in each case and Para4 (I tovii) whichever is applicable. 4. I) Change in age Sl. No. Name of the person whose age is to be changed Age as recorded on the food card Date of birth and present age Relationship with H.O.F. Remarks. ii) Change of Address (within same Circle) Old address New address where shifted Date of shifting Remarks. iii) Change of H.O.F. Name of H.O.F. (Old) Name of new H.O.F. Age of new H.O.F. His/her relation with old H.O.F. Reason for change iv) Change of FPS v) Change of mode of drawal vi) Change in category New F.P.S. No. Reason for change Present Change required Present Change required Place & State to which belong Weekly Bi-Weekly Monthly Weekly Bi-Weekly Monthly vii) Correction of inaccuracy in food card inaccuracy if any correction to be made Declaration:- I shall be liable for punishment under the Delhi Specified Food Articles (regulation of Distribution) Order, 1968 if above information is found false or incorrect. Signature/T.I. of Head of Family Counterfoil Form 1. Name of the head of the Family 2. Date of application 3. Regd. No. of application Signature of Counter Clerk (FOR OFICE USE ONLY) 1. Date on which change made in food card............... 2. Nature of change made in food card No.......registered with FPS No............. Regd. No. necessary amendment has also been carried out in the F.P.S. vide register of the Circle. Signature of IHQ/FSO Signature of Counter Clerk I/We have received my/our food card after necessary correction. Date Signature/T.I. of Card Holder Inspector's post-verification report Visited on.........and contacted Shri..............H.O.F./Other members of the family/neighbourer holding food card No....... registered with FPS No......... The above mentioned change has been post verified by me and is found to be correct/incorrect on account of the following reasons and necessary rectification has been done/requires to be done in the food card. Order of F.S.O. Signature of Inspector.......... Full Name................ Date.................. Signature of I.H.Q./F.S.O........ Full Name.............. Date.................
