Form: VIII-R (Application form for conversion of RKSY-II card for erstwhile AAY/BPL beneficiary)

To
The Inspector Food & Supplies,
... Block, District
Sir,
I would like to inform you that I am Erstwhile Antyoday Anna Yojana (A.A.Y) Family/ Erstwhile Below Poverty line (B.P.L) Beneficiary. So I am requesting you to please
exclude My name/ Name of my family member name from Rajya Khadya Suraksha Yojana-II (RKSY-II) and include
My name/ Name of my family member name in RKSY-I or NFSA list.
Block - Gram Panchayet Enumaration Block No.- Village Samsad - Village -
Mouza Address- Mobile no. (of any family member) -
RKSY-II card Name of the family member of the family who possesses Gender (1) EPIC no. Relation with Date of Birth Category & Number of Reason(s) for inclusion
Number the RKSY-II card Or Head of the / Age Erstwhile AAY/BPL (please mention the
(Copy of RKSY- (2) Aadhaar no. Family (as on 1st Ration card appropriate sl no. of
II card should [Please strike out (in case of Head of January of (Copy of Erstwhile Deprivation Index (s) as
be attached) current year) AAY/BPL Ration card
which is not the family, please noted on the reverse side
should be attached
inapplicable between mention as
(1) & (2)] Head)

I do hereby also declare and affirm that

(1) The auto exclusion ..indices as referred on the reverse page is/are applicable in case of my family (write the Sl. No. of the Index) .
(2) None is applicable.
[Please strike out which is not inapplicable between (1) & (2)]
___________________
Signature of Applicant

-----------------------------------------------------------------------Return this portion to the Applicant-----------------------------------------------------------------------------------------------------

------------- The application form VIII-R has been received from Shri / Smt ., Address,
Village.
__________________________
Signature of Authority (with Seal)
 Reason for inclusion

Sl. Deprivation Criteria The indices for Auto Exclusion For Rural areas
No. i. Motorized Two / Three / Four Wheelers / Fishing
1 Households without shelter boats (which require registration).
2 Destitute / living on alms ii. Mechanized Three / Four wheeler agricultural
3 Manual scavengers equipment such as tractors, harvesters etc.
4 Primitive Tribal Groups iii. Kisan Credit Card with the credit limit of Rs. 50,000
5 Legally released bonded labourers and above.
6 Households with only one room with kucha walls and kucha roof. iv. Households with any member as Government
7 Households with no adult member between age 16 to 59. Employee : Gazetted / non-gazetted / Central / State
8 Female headed households with no adult male member between age 16 to 59. Government / PSU government-aided autonomous
9 Households with any disabled member and no able bodied adult member. bodies and local bodies.
10 SC/ST households. v. Households with non-agricultural enterprise registered
11 Households with no literate adult above 25 years. with the Government.
12 Landless households deriving the major part of their income from manual casual labour. vi. Any member in the family earning more than Rs.
13 Not any of the above but the family is insolvent, want to have food-grains through Ration 10,000 per month.
vii. Paying income tax or professional tax.
viii. Households with three or more rooms with all rooms
having pucca walls and pucca roof.
ix. Owning refrigerator.
x. Owning landline phones.
xi. Households owning 2.5 acres or more irrigated land
with at least one irrigation equipment such as diesel /
electric operated bore well / tubewell.
xii. 5 acres or more land irrigated for two or more crop
seasons.