COMMON APPLICATION FORM

RURAL
Food & Supplies Department Government of West Bengal

I. Application For √ Fill part

Old Form 3: Inclusion of Full Family under NFSA/RKSY A, B, C, F

Old Form 4: Inclusion of left out Family members under NFSA/RKSY/ GEN A, B, E, F
Old Form 5: Rectification of spelling mistake in name / age/ address in existing Digital ration card A
Old Form 6 / Change of FPS due to shifting of full family / partial family/ Individual due to Marriage/ Divorce/ A, B, C, D,
13 /14: others E
Old Form 7: Application form for surrendering Digital Ration Card due to Death / Migration / Voluntarily A, D
Old Form 8: Application form for conversion of another category of DRC to RKSY I A, B, F
Old Form 10: Application form for Non-Subsidized Ration Card. (Subsidized Food Grain Not Required) A, B, C
A. Applicant Details ( Name, Age & DOB of applicant should be mentioned as in Aadhar / Birth Certificate)
Name of the 1st Applicant
Name of father/ mother
Relation Father/Mother/Son/Daughter/Brother/Sister/Husband/Wife/Son-in-law/Daughter-in-law
Gender M F O Mobile No.
Date of Birth Aadhar No
Category If Applicable Person with Disability Sex Worker Leprosy Patient HIV Patient
DRC No. (If available) Caste SC ST Others. In case of ST, Lodha, Birho, TOTO
Type AAY PHH SPHH RKSY I RKSY II Old Paper Ration Card
Name of the 2nd Applicant
Name of father/ mother
Relation Father/Mother/Son/Daughter/Brother/Sister/Husband/Wife/Son-in-law/Daughter-in-law
Gender M F O Mobile No.
Date of Birth Aadhar No
Category If Applicable Person with Disability Sex Worker Leprosy Patient HIV Patient
DRC No. (If available) Caste SC ST Others. In case of ST, Lodha, Birho, TOTO
Type AAY PHH SPHH RKSY I RKSY II Old Paper Ration Card
Name of the 3rd Applicant
Name of father/ mother
Relation Father/Mother/Son/Daughter/Brother/Sister/Husband/Wife/Son-in-law/Daughter-in-law
Gender M F O Mobile No.
Date of Birth Aadhar No
Category If Applicable Person with Disability Sex Worker Leprosy Patient HIV Patient
DRC No. (If available) Caste SC ST Others. In case of ST, Lodha, Birho, TOTO
Type AAY PHH SPHH RKSY I RKSY II Old Paper Ration Card
Name of the 4th Applicant
Name of father/ mother
Relation Father/Mother/Son/Daughter/Brother/Sister/Husband/Wife/Son-in-law/Daughter-in-law
Gender M F O Mobile No.
Date of Birth Aadhar No
Category If Applicable Person With Disability Sex Worker Leprosy Patient HIV Patient
DRC No. (If available) Caste SC , ST, Others. In case of ST, Lodha, Birho, TOTO
Type AAY PHH SPHH RKSY I RKSY II Old Paper Ration Card

B - Address of the Applicants -To be Filled For Old Form 3,4,6,8,10 & 13
Sub-Division Post Office
Block/Municipality/Muni.Corp District
Gram Panchayat/Locality
Village/Street Pin Code
 COMMON APPLICATION FORM
RURAL
Food & Supplies Department Government of West Bengal
C. Nearest Fair Price Shop - To Be Filled For Old Form 3,6,10,13
Ration Shop Name
Ration Shop Code
D. Miscellaneous Details - To be filled for Old Form 6,7,13,14
Surrender Ration Card (Old Form 7) Reason Death Migration Voluntarily
Change Of Ration Shop Due to Shifting Of (Old Form 6/13/14) Full family Partial family Marriage/Divorce/Other
E. Details Of Any Member Of Family Where Applicant Wants To Join – To be filled for Old Forms 4, 14
Name Of Any Family Member Having Ration
Card Whose Age Is More Than 18 Yrs
Ration Card No Type AAY PHH SPHH RKSY I RKSY II
Aadhar No Mobile No
Relation with the person Husband Son-in-law Son
Wife Daughter-in-law Daughter
F: Declaration : To be filled for Old Forms 3, 4, 8

I certify that I / my family is /are applying for new ration card or modifying /conversion of category of ration card on the
following Auto-exclusion Criteria that we have (Tick (√) where applicable)
a motorized two/three/four wheelers / fishing boats (which require registration). / mechanized three / four wheeler
agricultural equipment such as tractors, harvesters etc / Kisan Credit Card with the credit limit of Rs. 50,000 or above
/ one or more family members who are Gazetted /non-gazetted Government Employee of Central / State Government /
PSU/ government-aided autonomous bodies and local bodies / is not a household with non-agricultural enterprise
registered with the Government / a member in the family earning more than Rs. 15,000 per month / a family
member paying income tax or professional tax / a household with three or more rooms with all rooms having pucca
walls and pucca roof / own a refrigerator / own landline phones / 2.5 acres or more irrigated land with at least one
irrigation equipment/ 5 acres or more of irrigated land growing two or more crops per season.
that I/ my family satisfies following Deprivation Criteria: (Tick (√) where applicable.
We are a household without shelter / We are destitute / living on alms / We are manual scavengers / Primitive
Tribal Groups- Toto,Birhor & Lodha / Legally released bonded labourers / We are Household with only one room
with kutcha walls and roof / Households with no adult member between age 16 to 59 / Households with no adult
member between age 16 to 59 / Households with any disabled member or no able-bodied adult member / SC /ST
households / Households with no literate adult above 25 years / Landless households deriving the major part of their
income from manual casual labour.
I do hereby declare that:
1. all inputs and information given above are true to the best of my knowledge and the application may be rejected, or
the Ration Card, if issued, may be cancelled if any information furnished here is found to be false.
2. the department may take legal action against me for furnishing wrong information or hiding any relevant
information.
3. I have submitted Aadhaar Data voluntarily.
4. the Department of Food & Supplies, Government of West Bengal may send any information through SMS to my
mobile.
Please Note: In case of application for new ration card for full family, age of at least one applicant
of the family should be more than 18 years of age.
Documents to be submitted:
1. Copy of Aadhar of all applicants except minor child aged below 5 yrs & does not possess Aadhar. 2. Copy of Birth
Certificate(child aged below 5 yrs & does not possess Aadhar) 3.Copy of Aadhar & DRC of any family member in case
applicant Wants To Join in a family.4. Copy of Death Certificate, if Ration Card surrender due to death.

Signature of the applicant / Adult member of family whose details is mentioned in Part E

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Aadhar Number of the 1st applicant / Aadhar number of the family member as mentioned in Part E (In
case of addition of new member or modification of the minor applicant not having Aadhar)

Date & time of receiving of application