ANNEXURE "H" DECLARATION (See clause 7 (1) of G.D.D. Controlled Commodities (Regulation of Distribution Order 1966) Taluka _____________ Panchayat Municipality ________________village_________ Word Wado ______________ *H.No._____________ Old Ration Card No.________ other evidences F.P. Shop No. ________________ Kerosene Dealer ___________________________ Name of the Head of the Family ( in full )___________________________________ Name of the persons in the family including Head of the family Relation to the Head of the family Age IC.No. 2.Total number of persons __________(Children (upto age 5) ) _________________ ( Adults ( from 5 onwards) ) ____________ 3.What is the stock held by the Head of the Family or any member of the family: ( Paddy _________________ quintals) (Rice ____________________________ quintals ) 4. Total monthly income of all members of the family ______________Rs._________ 5.Whether the house is electrified or not ____________________________________ 6.No. of L.P. Gas connection in the family _____________________________________ Name of the Agent Consumer No.s 7. I do solemnly declare that : i) I or any of the above mentioned member of the family do not possess ration card in my/their names nor my/their name/names is/ are included in the ration card elsewhere. ii) The above statement is complete and true to the best of my knowledge and belief and I undertake to hold myself responsible if any part or whole thereof is found to be false. Place:-________________ Date:-_________________ Signature/Thumb impression of the Head of the Family. Please mention H.No. given by Panchayat/Municipality or name of the Building/Flat No. Mention correct name and ages as per Birth Certificate. The declaration should be signed by the Head of the Family only. FOR OFFICE USE ONLY Card No. allotted ____________ Sr.No. of Declaration _________________________ Name of F.P.Shop Owner/Society _______________________ No._______________ Name of the Kerosene Retail Dealer ________________Location________________ DETAILS OF CHANGES :- Date Addition Deletions Surrender Reasons for duplicate R.C. Change of F.P.Shop Remarks Initials Ch Ad Ch Ad Ch
