* Please Read the Instructions Before filling this Declaration Form ** Mandatory Fields are in RED

House Hold General Information

Declaration Form No:xxxxxxxxxxxxxxxxxx Card Type:(1) Existing Ration Card No:
Mandal / Muncipality LPG Company
Address Details: Mandal Muncipality LPG Connection: YES NO BPCL HPCL IOCL Others
Name: Name
LPG Consumer
Gram Panchayat: FP Shop No: LPG Distributor Name
No:

Village / Ward No: Door No/ Building: NPR TIN: Family Count

Care of: Colony

Street Landmark:

District / State: PIN Code:

Head of the Family KYR+ Details Signature / Thumb

Full Name: Mobile No: Email id: Print

Relationship(with Head of Bank Name with Branch

SELF DOB(dd-mm-yyyy): Age: Bank A/c No:
the family) :(2) Code
DOB Type:(3) Gender: MALE FEMALE TRANSGENDER NREGA Card No: Pension ID: SHG No:

Marital Status:(4) Disabled: YES NO

Edu.Qualification:(5)
( ) POI:(8):
( ) POA:(9):
( )

Occupation:(6) Caste Category:(7) Introducer Name: (10) Introducer UID: (11)

Name of Parent / Spouse
Relation Name:(13)
/ Guardian: (12)
Relation Enrolment
Relation UID:(15)
ID:(14)
Family Member 1 Signature / Thumb
Full Name: Mobile No: Email id: Print
Relationship(with Head of Bank Name with Branch
SELF DOB(dd-mm-yyyy): Age: Bank A/c No:
the family) :(2) Code
DOB Type:(3) Gender: MALE FEMALE TRANSGENDER NREGA Card No: Pension ID: SHG No:

Marital Status:(4) Disabled: YES NO

Edu.Qualification:(5) POI:(8): POA:(9):

Occupation:(6) Caste Category:(7) Introducer Name: (10) Introducer UID: (11)

Name of Parent / Spouse
Relation Name:(13)
/ Guardian: (12)
Relation Enrolment
Relation UID:(15)
ID:(14)
Family Member 2 Signature / Thumb
Full Name: Mobile No: Email id: Print

Relationship(with Head of Bank Name with Branch

SELF DOB(dd-mm-yyyy): Age: Bank A/c No:
the family) :(2) Code
DOB T
Type:(3)
(3) G d
Gender: MALE FEMALE TRANSGENDER NREGA Card
C d No:
N P
Pension
i IDID: SHG N
No:

Marital Status:(4) Disabled: YES NO

Edu.Qualification:(5) POI:(8): POA:(9):

Occupation:(6) Caste Category:(7) Introducer Name: (10) Introducer UID: (11)

Name of Parent / Spouse

Relation Name:(13)
/ Guardian: (12)
Relation Enrolment
Relation UID:(15)
ID:(14)
Family Member 3 Signature / Thumb
Full Name: Mobile No: Email id: Print

Relationship(with Head of Bank Name with Branch

SELF DOB(dd-mm-yyyy): Age: Bank A/c No:
the family) :(2) Code
DOB Type:(3) Gender: MALE FEMALE TRANSGENDER NREGA Card No: Pension ID: SHG No:

Marital Status:(4) Disabled: YES NO

Edu.Qualification:(5) POI:(8): POA:(9):

Occupation:(6) Caste Category:(7) Introducer Name: (10) Introducer UID: (11)

Name of Parent / Spouse

Relation Name:(13)
/ Guardian: (12)
Relation Enrolment
Relation UID:(15)
ID:(14)
Family Member 4 Signature / Thumb
Full Name: Mobile No: Email id: Print

Relationship(with Head of Bank Name with Branch

SELF DOB(dd-mm-yyyy): Age: Bank A/c No:
the family) :(2) Code
DOB Type:(3) Gender: MALE FEMALE TRANSGENDER NREGA Card No: Pension ID: SHG No:

Marital Status:(4) Disabled: YES NO

Edu Qualification:(5)
Edu.Qualification:(5) POI:(8): POA:(9):

Occupation:(6) Caste Category:(7) Introducer Name: (10) Introducer UID: (11)

Name of Parent / Spouse
Relation Name:(13)
/ Guardian: (12)
Relation Enrolment
Relation UID:(15)
ID:(14)

FOR OFFICE USE:

Enclosures Produced: Verification/Autherization Officer ( RI/ASO/MRO/VRO) Details, Signature & Seal For Enrolment Purpose

1 Incharge Verification Status:

2 Data Entry Completion Status:

3 Biometric Completion Status:

4 Household Enrolment Receipt Issued:

Enrolment Receipt
5
No.
6 PLACE: DATE:
FORM FILLING INSTRUCTIONS
(1) Card Type : Pink, White, Anthyodaya, Annapurna POA: (Proof of Address) Any of the following supporting Documents should be submitted
Relationship: Husband, Wife, Son, Daughter, Father, Mother, Grand Son, Grand Daughter, Grand Mother, Grand Father, Passport, Bank Statement/Pass book, Post office a/c statement, Ration Card, Voter ID,
(2)
Daughter-in-Law, Son-in-law, Father-in-law, Mother-in-law, Sister, Brother, Others. Driving Licence, Government Photo ID Card, Electricity Bill, Water Bill, Telephone
Landline Bill, Property Tax Receipt, Credit card Statement, Insurance Policy, Signed
(3) DOB Type: Date of Birth Type: Verified, Declared, Approximate
Letter having
g Photo from Bank/Registered
g Company/
p y Recognized
g Educational Institute
(4) Marital Status: Never Married, Currently Married, Widowed, Separated, Divorced. (9) on Letter head, NREGA Job card, Arms Licence, Pentioner Photo Card, Freedom fighter
Photo ID Card, Kisan Pass Book, CGHS/ECHS Photo card, Certificate of Address having
:(5) Qualification: Illitrate, Literate, SSC, Intermediate, Graduate, Post Graduate, Ph.D.
Photo issued by MP or MLA or Gaztt.A Officer on Letter Head, Certificate of Address
Occupation: Government Service, Private Service, Cultivator, Agriculture Labour / Manual Labour, Doctor/CA/ issued by Village Panchayat head or its equivalent authority of rural areas, IT
(6)
Lawyer/Consultant/ Shopkeeper, Household duties, Student, Dependent, Pensioner, Begger, Rentier, Others Assessment order, Vehicle Registration Certificate, Registration of Sale / lease / Rental
(7) Caste Category: SC,ST,BC,OC,Others Agreement.

POI: (Proof of Identitiy) Any of the following supporting Documents should be submitted. (10) Introducer Name: Name of the Introducer (appointed by Registrar) , if any
Passport, PAN Card, Ration Card/PDS Photo ID, Voter ID, Driving Licence, Government Photo ID Card, NREGA Job card, Photo (11) Introducer UID: UID Number of Introducer.
ID by recognized Educational Institute, Arms Licence, Photo Bank ATM Card, Photo Credit Card, Pention Photo Card, Freedom (12) Name of the Parent / Spouse / Guardian: Full Name of either Parent or Spouse or Guardia
(8) fighter Photo ID Card, Kisan Pass Book, CGHS/ECHS Photo card, Postal ID card, Certificate of Identity having photo issued by
Gestt. A Officer. (13) Relation Name: Wife, Husband, Mother, Father, Guardian
(14) Relation Enrollment ID: Enrollment ID of the Person in Field no. 14 , if he/she not having a
(15) Relation UID: UID of the Person in Field no. 14 if he/she is already having UID Version 1.3 (25-08-2010)+Q56+Q5