GOVERNUENTOF TAMILNADU

CIVILSUPPLIESANDCONSUMER PROTECTIONDEPARTTENT
APPLICATION FOR FATUIILY
PROOF.OF.RESIDENCE CARD
ZONE/TALUK No (Computergenerated)
Applicatircn

Signature(or)
Thumblmpression of Applicant Passport size photo
of
Note: Applicationshouldbe Head of Family
filledup in blackink
5cmx3cm

2.Fathe/s/ Husband'sName
{ame(English)

3. a. Full Address: b. Year from which llvlng In thls address:

Telephone: Mobile:

4. Detailsof familymembers(writeheadof bmily first):

:lectionPhoto
UonthlyIncom€dentityCard
il.Nc Name Date of birth )el Nationality Relationship Profession (ln tlumber
Rs.)
'lf
above18vears)
1
2
3
4
5
6
7
I
9
10

Applicantsare advisedto collectan acknowledgement slip with serialnumberafter submissionof applicationin the
Taluk or Zonal office.Acceptedapplicationswith necessarydocumentsas abovewill be approvedby TSO or AC
concernedand card deliveredwithin 7 days of applicationreceivedby RPAD/Courier
 5 Proof of resldence: Enclosecopy of any one documentbelowas proofof residence(Applicant'sname and
addressmustappearin the document)

Pleasetick ( ) DocumentlD No.

1 /oter ldentityCard

2 )ass Port

3 :ront pageof Bank Passbook

4 vledicalInsuranceldentityCard
5 )rivinqLicence
6 dobile/ LandlineBill

6. Certificate: ll certifuthat I and my familymemberslistedin this applicationare indiancitizens.I also cerifythat

me or membersof my family listedabove do not find place in any famity/rationcards issuedby any State Govemment
in India. The above particularsare true to my knowledge. lf it comesto noticeat a laterdate that particularsgiven by me
are eitherwrong or contraryto truth, I am awarethat the proof-of- residencefamilycard issuedto me will be cancelled
and actionpursuedagainstme underEssentialCommodities Act (Act 10 of CentralAct),1955.I am awarethat Proofof
residencefamilycardcannotbe convertedintoa regularfamilycard in future.I am awarethat I shallhaveto pay Rs.100
alongwiththis applicationform and this amountwill not be refundedif the applicationis foundineligible.
Place:

Date: Signatureof Headof Family

3r9otel6 uerftig rougrir(For office use only)

)istrict Code )istrict Headquarter? l/es \,lo LocalBodyName

l-alukCode -PG: )ilCompanl
)lace Code 3ylinders LocalBodyGrade:
lP ITP / Mplty/ Corporation
\rea Code )ealer
/VardCode lard Option:PROOF-OF-RESIDENCE
FAMILYCARD actrd,oo gripnerfr Ouuin:
jhop Code ncome(Monthly)
itreet Code :ategory 3ivil :orest >olice IAAY 4d goerufi / orir- ogrirodr
tgtorelr Or.ru.ri,:
>inCode )ld FamilvCard No:
fff dreo6g0oneni glriqdedf,q

ooOnrnr]urb
.-lDerr grwrllr / qrLL c{r:rd5e) dgl|D|$|I gogt.

oeOu.rnriuri

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