No White Ration Card Declaration for Health Cards

DECLARATION TO BE FILLED BY GOVERNMENT EMPLOYEE BEFORE DRAWING AND DISBURSING OFFICER.

I Sri/Smt (Surname)___________________________
(Actual Name)______________________________
S/o W/o D/o ____________________________________ R/o(H.No.)_____________________________
Locality _____________________________________ Village:___________________________________
and Mandal _____________________________
working as ____________________________________
in the office of the _____________________________________________________________________

do here by declare that I have not possessed BPL Ration Card(WAP/AAP/YAP/TAP/RAP) in my name or
in any of my family member name.
The above facts are true and correct to the best of my knowledge and belief, it is found incorrect in
future, I will be liable for punishment under CCA Rules along with action under PDS Control Order, 2010.

Signature of the Employee
Name: ____________________
Designation

//Before me//
Drawing and Disbursing Officer
O/o__________________
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