Food Supply and Consumer Welfare Department

RC No and Form No: *

OTP

old Residential Address

District *

Block/ULB*

GP/Ward *

Village/Area*

Plot No/Qtr No(for ULBs) :

Pincode :

Present Residential Address

District *

Block/ULB*

GP/Ward *

Village/Area*

Plot No/Qtr No(for ULBs) :

Pincode :

Beneficiary Details

	Full Name	Gender	Date of Birth	Relationship with eldest lady of the family	EPIC No.	Aadhar No.	Aadhar Enrollment No.	Father Name	Spouse Name	Special Case(If Any)

Other Info

Rice FPS Name *

Auto Inclusion Criteria*

Mobile No:

Bank Name*

Bank IFSC Code *

A/C No:

A/C Holder Name*