Form: VI-R

@˘ÃyõyM˛ÈˆÏúÓ˚ ãòƒ Form: VI-R (Application form for Change of Ration Shop (FPS) in respect of families already Included in NFSA/RKSY eligible family List)
(Please fill PART-I or PART-II or PART-III whichever is applicable)
ˆÓ˚üò ˆîyÑ˛yò ˛ô!Ó˚Óì≈˛ˆÏòÓ˚ ãòƒ
To
The Inspector Food & Supplies,
............................................................... Block
Sir,
The names of the members, as noted here-in-under has appeared in the Rajya Khadya SurakshaYojana (RKSY) / National Food Security Act (NFSA) List. I / We apply for change of the Fair Price Shop (FPS) as recorded in the
Ration Card.
Village : Gram Panchayet : P.O. : Mobile No. : e-mail ID :

Pin Code : District : P.S. : (of any family member)*

PART-I : FPS shifting for all members of family
, ,
Name of the beneficiary Card no. Type of Card Father s/Husband s name Name of the Head of the family Mention the name & Mention the name and Reason for PAN No.
(AAY/PHH/ no. of Ration Shop as no. of the Dealer of the change of
SPHH/RKSY-I/ recorded in the Ration Shop of your Ration Shop
RKSY-II) Ration Card Choice / Preference

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OR
PART-II :Change of FPS due to shifting of a member from one family to another family due to marriage etc.

Name of the applicant Ration Card no. of Type of Card Ration Card no. of Head of the Relationship of the applicant
the applicant (AAY/PHH/SPHH/ Family where the applicant with Head of the Family
RKSY-I/RKSY-II) has been shifted where shifting is requested

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OR
PART-III :Change of FPS for shifting more than one member to a new address

Name of the applicant Ration Card no. of the Type of Card Ration Card no. of Head of the Name of FPS where shifting
applicant (AAY/PHH/SPHH/ Family* is applied for
RKSY-I/RKSY-II)

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*Please write “Head” against Head of the Family.

Signature of Applicant
...................................................................................... ...................................................................................... Return this portion to the Applicant ........................................................ ........................................................ ........................................................
    

The application form VI-R (for Change of Ration Shop) in respect of families already Included in NFSA/RKSY eligible family List) has been received from Shri /Smt ....................................................................................................

..................................................................................................................., Address.............................................................................................................................................., Village .................................................................................................

Signature of Authority (with Seal)

SPL-2019