Government of West Bengal Form.3 Application for replacement of mutilated/defaced or lost Ration Card [Vide Paragraph 12 of the WBPDS(M&C) Order.2013] Applicant's Name on sess Address: House No. Fat NO soesosssesecenese WatrNO oo. . StreevRoad/Lane Para. Village’Municipatity Post. sae Name of Head of family Sl. | Name ofthe | Age [Relationship] Name of | Reasons | Ration | FPS.No. | FolioNo.| General No. | family member with the | fathers Card Diary No. ‘whom hhead of | husband No. of the poi Ration Card the family station. (in isto be replaced case of lost Card) o @ | © © o @) o (19) ‘The circumstances under which the Ration Cards were lost, mutilated or defaced. | solemnly affirm that the above statements are rue to my Knowledge and belief, Signature of LT: of the applicant ‘Counterfoil of Form-3 Received one application fromSri/Smt 7 sais ansatci Address Receipt SILNO. esse nnn & Dat, Retumnable Date. Signature ofthe receiving official N.B.- To obtain or attempt to obtain a ration card by furnishing false information or suppressing any information is an offence under Section 7 of Essential Commodities Act (Act 100 1955) and is punishable with imprisonment fora term which may extend up to seven years or fine or both.(FOR OFFICE USE ONLY) Rotumable Date, SI. No. Date. Report of Enquiry Officer Order of the Ration Card Issuing Authority. Serial No. of the new Ration Card{S) issued in lieu of the Lost or mutilateddefaced Ration Cards)... Received the Ration Cards Signature or L. ofthe applicant or his/her authorised representative, Signature ofthe Delivery Official