DECLARATION FORM

Card No

: 365370740397

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 797320031804

Name of Head of Household

: Gundeboina Saritha

Father/Husband Name

:-

Address

: Qtr No. 73,Qtr No. 73,

Rajendra Nagar, P.W.D Otrs,
Ward-22(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 37834

Family Members Details

SNo

Name

UID

Photo

Gundeboina Saritha

797320031804

Gundeboina Nagaraju

508776344905

Gundeboina Vijaya Kumar

402944100188

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740435

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 476160489004

Name of Head of Household

: Aturi Anusuya

Father/Husband Name

:-

Address

: 5-5-115/1,5-5-115/1, Rajendra
Nagar, Manikyamma Colony,
Ward-19(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Aturi Anusuya

476160489004

Aturi Surender Rao

521386485211

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740468

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 460242287148

Name of Head of Household

: Billa Chinna Rao

Father/Husband Name

:-

Address

: 78(1-10-25),78(1-10-25),
Rajendra Nagar, P W D Colony,
Ward-19(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: CX87630

Family Members Details

SNo

Name

UID

Photo

Billa Chinna Rao

460242287148

Billa Koteswaramma

641026089193

Billa Madhusudhan Rao

581169305131

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740488

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 712384355009

Name of Head of Household

: Shabad Krishnamma

Father/Husband Name

:-

Address

: 1-9-205,DALITHA BASTHI,
RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 646904

Family Members Details

SNo

Name

UID

Photo

Shabad Krishnamma

712384355009

Shabad Madhavi

608389658928

Shabad Manila

842691593352

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740535

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 263489639540

Name of Head of Household

: Shareefa Bee

Father/Husband Name

:-

Address

: 1-7-28,1-7-28, Rajendra Nagar,

Rajendra Nagar, Ward-19(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 612934

Family Members Details

SNo

Name

Shareefa Bee

UID

Photo

263489639540

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740538

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 717059376063

Name of Head of Household

: Kothapeta Meena

Father/Husband Name

:-

Address

: 41-9-207,DALITHA BASTHI,
RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Kothapeta Meena

717059376063

Kothapeta Joanna Josowha

407326143417

Kothapeta Sasha Josowha

371998872501

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740541

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 828810319719

Name of Head of Household

: Meedhara Urmila

Father/Husband Name

:-

Address

: 1-8-161,1-8-161 rajendar nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo
1

Name
Meedhara Urmila

UID

Photo

828810319719

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740543

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 456994625486

Name of Head of Household

: Ch Parasuram

Father/Husband Name

:-

Address

: 1-9-332/2,1-9-332/2 Rajendra
Nagar Hanuman Nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Ch Parasuram

456994625486

Ch Maraiah

546866125261

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740553

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 574071488637

Name of Head of Household

: Nafeesa Begum

Father/Husband Name

:-

Address

: 1-1-212/1/D,BANSILAL
NAGAR, RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 254440

Family Members Details

SNo

Name

UID

Photo

Nafeesa Begum

574071488637

Mohammed Anwar

810494181345

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740556

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 798585737579

Name of Head of Household

: Jaggopu Kamalamma

Father/Husband Name

:-

Address

: 1-9-368/4,RAJENDRA
NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 15624

Family Members Details

SNo

Name

Jaggopu Kamalamma

UID

Photo

798585737579

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740565

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 339641575051

Name of Head of Household

: S.Manamma

Father/Husband Name

:-

Address

: 1-8-89,rajendra nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

S.Manamma

UID

Photo

339641575051

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740584

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 587260509996

Name of Head of Household

: M Muthamma

Father/Husband Name

:-

Address

: 1-8-86,1-8-86,RAJENDRA
NAGAR R R

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

M Muthamma

587260509996

M Vinay Kumar

368804356063

M Praveen Kumar

673790510671

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740589

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 234370453928

Name of Head of Household

: Kasi Tarabai

Father/Husband Name

:-

Address

: 1-8-107/1,1-8-107/1, Rajendra
Nagar, Dalitha Basthi, Ward20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 612333

Family Members Details

SNo

Name

Kasi Tarabai

UID

Photo

234370453928

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740593

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 832573464024

Name of Head of Household

: MAGGIGA SHUKKAMMA

Father/Husband Name

:-

Address

: 1-8-115,RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 645086

Family Members Details

SNo

Name

UID

Photo

MAGGIGA SHUKKAMMA

832573464024

M LINGAM

246797394738

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740607

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 473532866333

Name of Head of Household

: Kaliwale Komalamma

Father/Husband Name

:-

Address

: 1-8-48,rajendra nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

Kaliwale Komalamma

UID

Photo

473532866333

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740732

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 488925322110

Name of Head of Household

: Sakkuri Jayasri

Father/Husband Name

:-

Address

: 5-5-30/2,RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 38121

Family Members Details

SNo

Name

Sakkuri Jayasri

UID

Photo

488925322110

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740811

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 340206570747

Name of Head of Household

: Koduru Shobha

Father/Husband Name

:-

Address

: 1-8-29,1-8-29, Rajendra Nagar,

Ambedkar Nagar, Ward-19(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Koduru Shobha

340206570747

Koduru Shashikanth

353763558712

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740861

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 814290123335

Name of Head of Household

: Hamida Begum

Father/Husband Name

:-

Address

: 1-7-15,Rajendra Nagar,
Rajendra Nagar, Ward-20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 603696

Family Members Details

SNo

Name

Hamida Begum

UID

Photo

814290123335

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740879

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 332027529519

Name of Head of Household

: r shailaja

Father/Husband Name

:-

Address

: 7-116,RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

r shailaja

332027529519

swapna

317611984459

ramya sree

307668701012

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740896

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 737039881660

Name of Head of Household

: Parvatha Lakshmi Narsa

Father/Husband Name

:-

Address

: 1-9-56,1-9-56, Rajendra Nagar,

Dalitha Basti, Ward-20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 25495

Family Members Details

SNo

Name

Parvatha Lakshmi Narsa

UID

Photo

737039881660

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740935

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 594397671460

Name of Head of Household

: Madhuru Yadamma

Father/Husband Name

:-

Address

: 1-8-171,1-8-171, Rajendra
Nagar, Dalitha Basti, Ward20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 612198

Family Members Details

SNo

Name

UID

Photo

Madhuru Yadamma

594397671460

Madhuru Swathi

418251826052

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740942

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 687175651377

Name of Head of Household

: Rachamalla Prameela

Father/Husband Name

:-

Address

: 1-9-164,Rajendra Nagar, Main

Village, Ward-20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 457432

Family Members Details

SNo

Name

Rachamalla Prameela

UID

Photo

687175651377

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740964

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 358487911528

Name of Head of Household

: Sabina Begum

Father/Husband Name

:-

Address

: 5-6-70/3,MANIKYAMMA
COLONY, RAJENDRANAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Sabina Begum

358487911528

Shaik Chand

779247634861

Aliya Begum

556882631821

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370740998

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 993949475140

Name of Head of Household

: SEEMA

Father/Husband Name

:-

Address

: 1-9-125,Rajendranagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

SEEMA

993949475140

KOMAL

983067625214

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741044

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 272855846609

Name of Head of Household

: Kandhada Manemma

Father/Husband Name

:-

Address

: 1-9-210,rajendra magar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Kandhada Manemma

272855846609

Kandhada Srikanth

524660588745

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741048

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 244377068842

Name of Head of Household

: Orsu Padma

Father/Husband Name

:-

Address

: 1-9-325,1-9-325, Rajendra
Nagar, Hanmun Nagar, Ward20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: CX4336109

Family Members Details

SNo

Name

Orsu Padma

UID

Photo

244377068842

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741070

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 652228336781

Name of Head of Household

: Vikarabad Chinna Jangaiah

Father/Husband Name

:-

Address

: 1-9-134,

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

Vikarabad Chinna Jangaiah

652228336781

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741072

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 807229071610

Name of Head of Household

: Bashpak Gnana Bhushana

Father/Husband Name

:-

Address

: 14/a,Attapur , sainagar ward

no3(v)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

Bashpak Gnana Bhushana

UID

Photo

807229071610

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741110

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 899923355069

Name of Head of Household

: Pamula Devamani

Father/Husband Name

:-

Address

: 1-9-212/1,1-9-212/1, Rajendra
Nagar, Ward-33(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

Pamula Devamani

UID

Photo

899923355069

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741117

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 629437551312

Name of Head of Household

: Gunja Lakshmamma

Father/Husband Name

:-

Address

: 1-9-188,rajendra nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

Gunja Lakshmamma

UID

Photo

629437551312

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741131

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 485436104961

Name of Head of Household

: Dharpally Madhavi Latha

Father/Husband Name

:-

Address

: 1-8-162,1-8-162, Rajendra
Nagar, Near Masjid, Ward-7(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 614268

Family Members Details

SNo

Name

UID

Photo

Dharpally Madhavi Latha

485436104961

Dharpally Supriya Bhatt

468307400387

Dharpally Anirudh Bhatt

354758234239

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741197

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 777943765912

Name of Head of Household

: Myla Basaveswari

Father/Husband Name

:-

Address

: 1-7-24/1,1-7-24/1 rajendar
nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 607697

Family Members Details

SNo

Name

UID

Photo

Myla Basaveswari

777943765912

Myla Venkateshwarlu

573950223906

Myla Parvatamma

470396108636

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741212

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 328879674685

Name of Head of Household

: P Balamma

Father/Husband Name

:-

Address

: 1-9-264,Ward-20

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

P Balamma

328879674685

P Nalinikanth

911398708575

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741222

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 293868362121

Name of Head of Household

: A Laxmamma

Father/Husband Name

:-

Address

: 1-9-212,Rajendra Nagar,
Dalitha Basthi, Ward-20(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

UID

Photo

A Laxmamma

293868362121

A Mahender

785741511377

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741240

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 881284175566

Name of Head of Household

: Sirigiri Bhagya

Father/Husband Name

:-

Address

Mandal

Family Members Details

SNo

Name

UID

Photo

Sirigiri Bhagya

881284175566

: 5-3-64,5-3-64, Rajendra Nagar,

Manikyamma, Ward-19(V)

Sirigiri Bhanuteja

439627224279

: CIRCLEIII(SAROORNAGAR)

Sirigiri Raviteja

256263054332

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

:
CARD HOLDER

1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741269

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 847237716039

Name of Head of Household

: Borra Chenamma

Father/Husband Name

:-

Address

: 5-5-101,5-5-101, Rajendra
Nagar, Ambedker, Ward-12(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

Borra Chenamma

UID

Photo

847237716039

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741311

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 225727465199

Name of Head of Household

: Eramollu Balamma

Father/Husband Name

:-

Address

: 5-5-59,5-5-59, Rajendra Nagar,

Manikyamma Colony, Ward19(V)

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 26088

Family Members Details

SNo

Name

UID

Photo

Eramollu Balamma

225727465199

Eramollu Balaiah

297918005793

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741323

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 683623203875

Name of Head of Household

: Kothapeta Sowbhagya

Father/Husband Name

:-

Address

: 1-9-207,RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 606503

Family Members Details

SNo

Name

Kothapeta Sowbhagya

UID

Photo

683623203875

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741336

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 824354263632

Name of Head of Household

: Pilli Neelamma

Father/Husband Name

:-

Address

: 5-6-150,RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 05883

Family Members Details

SNo

Name

UID

Photo

Pilli Neelamma

824354263632

Pilli Kasturi

846135229746

Pilli Ramesh

646325831050

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741399

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 839216098426

Name of Head of Household

: Asiya Begum

Father/Husband Name

:-

Address

: 1-9-4,rajendra nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 625689

Family Members Details

SNo

Name

UID

Photo

Asiya Begum

839216098426

Afsheen Ghaleer

597370523091

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741402

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 803507031266

Name of Head of Household

: Badugu Triloka Kumari

Father/Husband Name

:-

Address

: 1-9-176/1,DALITHA BASTHI,
RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 38842

Family Members Details

SNo

Name

UID

Photo

Badugu Triloka Kumari

803507031266

Badugu Prashanth Kumar

516261865814

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741420

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 316928507990

Name of Head of Household

: M VIJAYA LAXMI

Father/Husband Name

:-

Address

: 1-9-254,Rajendranagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: No

LPG Consumer No.

Family Members Details

SNo

Name

M VIJAYA LAXMI

UID

Photo

316928507990

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741424

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 275228941736

Name of Head of Household

: Jaitharam Yadamma

Father/Husband Name

:-

Address

: 1-9-189/1,DALITHA BASTHI,
RAJENDRA NAGAR

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

: 622039

Family Members Details

SNo

Name

Jaitharam Yadamma

UID

Photo

275228941736

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre

DECLARATION FORM
Card No

: 365370741439

Card Type

: AFSC

F.P Shop No

: 1583002

UID

: 212255290286

Name of Head of Household

: Pattipati Ramanamma

Father/Husband Name

:-

Address

: 1-8-224,rajendra nagar

Mandal

: CIRCLEIII(SAROORNAGAR)

District

: Ranga Reddy

Gas Connection :

: Yes

LPG Consumer No.

Family Members Details

SNo

Name

Pattipati Ramanamma

UID

Photo

212255290286

CARD HOLDER
1. I have (

) Ticked all the places / fields where there are NO mistakes

2. I have provided correct details at all places / fields, where there are mistakes / blanks / inclusions to be done.
3. All deletions to be done have been struck off.
4. All the members whose names are included in this card are my family members who reside with us and their names are not included in
any other FSC card anywhere in this State or Outside the State.
5. I am aware that the income of all the family members put together is not more than Rs.2 Lakh(in Urban Areas) / Rs1.5 lakh(in
Rural areas) per annum and I am also aware that the Scheduled Commodities that are supplied on the Food Security Card to be issued
shall be used only for my Household consumption and not for any pecuniary gains.
6. In case any information given above is proved to be false I am aware that I am liable for prosecution.
Signature of card holder
Sl No of the member

FP SHOP DEALER
1. I shall assist the Civil Supplies Department in ensuring the details on the card are accurate and the cardholders are eligible.
2. This form is submitted to me by the cardholder / member personally whose name is mentioned at Sl No:____ and to the best of my
knowledge, is accurate.
3. I affirm that the beneficiaries / cardholders are not fictitious and that they are residents in the area catered to by my FPS and I affirm
that I have no intention of illegal pecuniary gains by mis-representation.
4. I am aware that I am liable for action under the provisions of APS PDS control Order-2008 read with the provisions of the EC Act-1955
and any other law applicable, in case it is proved that I have contravened the said provisions..
Signature of FPS Dealer
FPS NO:________
Seal:.

FOR OFFICE USE

I have read the above carefully and found all the details are filled in and signed by the appropriate persons. On verification of the
details with aadhaar details, they are found to be genuine / not genuine.
Signature
VRO/Inspector

Page No.1

Signature
Tahsildar/ASO

Report Generated by Telangana Food & Civil Supplies Dept., Application Developed by National Informatics Centre