This document contains instructions and a declaration form for collecting household information for ration card or LPG connection purposes. It requests details about the head of household such as name, relationship to family, date of birth, gender, education level, occupation, caste, and contact information. It also has sections to provide the same information for up to 4 additional family members. The form must be signed and includes fields for office use such as verification details and receipt information. Mandatory fields are marked in red.

1. * 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) Gender:
G d MALE FEMALE TRANSGENDER NREGA Card No:
C dN Pension ID
P i ID: 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)

2. 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 Photo from Bank/Registered Company/ Recognized Educational Institute
g g p y g
(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