Application for DRC in Rural area if no member has DRC Form 3R
(গ্রামাঞ্চলে ক ানও পরিবালিি একটিও
সদলসেি DRC না থা লে DRC-ি জনে আলবদন)
(*) marked fields are mandatory
Auto-exclusion indices [Tick (√) where applicable]*
(You must fulfil all criteria to get a ration card)
I certify that I/my family, Tick
here
1. do not have any motorized two / three / four wheelers / fishing boats (which require registration)
2. do not have mechanized three / four wheeler agricultural equipment such as tractors, harvesters etc.
3. do not have Kisan Credit Card with the credit limit of Rs. 50,000 and above
do not have any member as Government Employee : Gazetted / non-gazetted / Central / State Government / PSU government-aided
4. autonomous bodies and local bodies
5. is not a household with non-agricultural enterprise registered with the Government
6. do not have any member in the family earning more than Rs. 15,000 per month
7. do not have any member paying income tax or professional tax
8. is not a household with three or more rooms with all rooms having pucca walls and pucca roof
9. do not own a refrigerator
10. do not own landline phones
11. do not have 2.5 acres or more irrigated land with at least one irrigation equipment
12. do not have 5 acres or more land irrigated for two or more crop seasons
Deprivation criteria [Tick (√) where applicable]*
(You must fulfil at least one criteria to get a ration card)
I certify that I/my family, Tick
here
1. is a household without shelter
2. is destitute / living on alms
3. is manual scavengers
4. is under Primitive Tribal Groups
5. is legally released bonded labourers
6. is a household with only one room with kucha walls and kucha roof
7. is a household with no adult member between age 16 to 59
8. is a Female headed household with no adult male member between age 16 to 59
9. is a household with _____(number to be given) disabled member(s) and no able bodied adult member
10. belong to SC/ST households
11. is a household with no literate adult above 25 years
12. is a landless household deriving the major part of their income from manual casual labour
A. Address Details*
District*
Sub-division*
Block*
Gram Panchayat*
Village *
Post Office*
Pin Code*
Police Station
Primary Mobile No* (for getting SMS from F&S Deptt.)
Alternate mobile/ whatsapp no.
email id (if any)
If you don’t want us to send e-bill and other important messages, tick the box
You may also apply online. Visit [Link]
B. Details of preferred Fair Price Shop (FPS) & Kerosene Oil Shop
FPS Name
FPS Code
Kerosene ShopName
Kerosene Shop Code
C: Details of members applying for DRC*(Aadhaar not mandatory for applicants below age of 5 years)
Name of the
Applicant* 1(HOF)
Date of Birth* D D M M Y Y Y Y Male Female Others
Father’s/Mother’s/Spouse’s Name
Aadhaar Number*
EPIC Number
Whether Person with Disability (PWD) Yes No
Name of the
Applicant* 2
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Father’s/Mother’s/Spouse’s Name
Aadhaar Number*
EPIC Number
Whether Person with Disability ( PWD)
Name of the
Applicant* 3
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Father’s/Mother’s/Spouse’s Name
Aadhaar Number*
EPIC Number
Whether Person with Disability (PWD) Yes No
Name of the
Applicant* 4
Relationship with the Head of Family*
Date of Birth* D D M M Y Y Y Y Male Female Others
Father’s/Mother’s/Spouse’s Name
Aadhaar Number*
EPIC Number
Whether Person with Disability (PWD) Yes No
[ ] I agree that all inputs given above are true to the best of my knowledge. I agree that this application may be rejected, or the Ration Card if issued, may be
cancelled if any information furnished here is found to be false. I also acknowledge that other legal action may be taken against me for furnishing wrong
information or hiding any relevant information, either at the time of application or at later stage.
Date: Signature /LTI of the applicant
Checklist of Documents [Ensure that these documents are attached with your application]
1. Address proof (Not required if address same as in Aadhaar){Passport/ Recent Electricity Bill/ Driving License /Income Tax Assessment Order/Recent landline
phone bill/post paid mobile bill}
[Link] of Aadhaar of all members
3. Copy of proof of Date of Birth of members less than 5 yrs. age not having Aadhaar {PAN card /Passport/ Govt. or PSU ID cards with photograph}
___________________________________________________Receipt_______________________________________________________
Received Application vide Barcode Number______________________________________________ for Form _________
Date………………… Signature and seal
You may also apply online. Visit [Link]
