Simplified Proforma for Services under RTS Act. Service No.

96 (a) and (b)

OAP (p[Ykgk g?BPB)

ckow BzH ;H;H^I

Photo of
Applicant
fpB?eko dh
c'N'

1.

Name of the Service/ ;/tk dk y/so

2.

Name of Applicant/ fpB?eko dk Bkw

3.

Name of Father/ fgsk dk Bkw

4.

Name of Husdband/ gsh dk Bkw

5.

Age of Applicant/ fpB?eko dh T[wo

6.

Male/ Female/ g[oP$fJ;soh

7.

Permanent Address/ gZek gsk

8.

Correspondence Address/
gZso ftjko bJh gsk

9.

Phone No./Mobile No.

c'B BzH$ w'pkfJb BzH
Correspondence e-mail/
JhHw/b nkJhHvhH

10.

Rural / Urban Area

11.

Aadhaar card No. (Attach Copy)

12.

BPL No./ rohph o/yk s'A j/mK dh ;{uh dk BzH (ekgh

BZEh)

13.

SC/BC/ GEN
n?;H;hH$ phH;hH$ iBob

14.

Husband/Wife alive or not?

eh gsh$gsBh fizdk j?<

15.

Monthly Income of husband and wife from all

sources
gsh$gsBh dh ;ko/ t;hfbnK s'A wkf;e nkwdB

16.

Agriculture land ( Chahi/Baraani)

tkjh:'r iwhB (ukjh$pokBh)

17. 1Bank Detail / p?Ae dk t/otk

6
.

Name of bank

Name of
Branch

Account No.

IFSC Code

w?A x'PDk eodk$eodh jK fe w/o/ tZb'A fdZsh rJh T[go'es ikDekoh ;jh tk do[;s j? ns/ e'Jh th sZE S[gkfJnk Bjh frnk,
i/eo fJj ;{uBK rbs gkJh iKdh j? sK w?A ;Ik dk Gkrhdko j'tKrk$j'tKrh.
(Signature of Applicant)
fpB?eko d/ j;skyo
Required Document/ b'VhAd/ d;skt/I

Attached copy/
ekgh BZEh

Voter Card or Voter List or Ration Card or Matriculation Certificate or Certificate from
Registrar Birth & Death As Age Proof (any one proof out of above) t'No ekov iK t'No ;{uh iK
okPB ekov iK d;thA dk ;oNhfce/N iK ofi;Noko iBw ns/ w"s tZb'A ikoh ;oNfce/N (ftZu'A e'Jh fJZe iBw
d/ ;p{s tZi'A )
iwhB ;pzXh fog'oN
s;dhe ehsk iKdk j? fe Pqh$Pqhwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHHHg[Zso$gsBh HHHHHHHHHHHHHHHHHHHHHtk;h HHHHHHHHHHHHHHHHd/ Bkw
(gsh^gsBh d'BK d/ Bkw) wkb foekov nB[;ko HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHJ/eV (ukjh$pokBh) tkjh:'r iwhB j?.

(gNtkoh d/ j;skyo)
s;dhe f;ckoP eosk d/ j;skyo (;w/s w'jo)

ubdk gzBkHHHH2

^2^

T[g wzvb w?fi;No/N dcso dh tos'A bJh

fJj fpB?^gZso dcso d/ vkfJoh Bzpo HHHHHHHHHHHHHHHHHHHHHHHHHfwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHokjhA gqkgs j'fJnk, tkfunk frnk,
tkuD T[gozs fB:wK$jdkfJsK nB[;ko fJj fpB?eko g?BPB$ftZsh ;jkfJsk bJh :'r gkfJnk frnk j? .

fpB?eko n:'r gkfJnk frnk j?, feT[Afe T[wo xZN j?$ nkwdB tZX j?$iwhB tZX j?.
gq'thIBb g?BPB wzBi{o eoB$ oZd fjZs g/P j?.

vhfbzr eboe$ ;jkfJe

fwsh

T[g wzvb w?fi;No/N

;w/s w'jo$fwsh

fibQk ;wkfie ;[oZfynk nc;o dcso dh tos'A bJh

fJ; e/; dh gVskb eotkJh rJh, gVskb fog'oN$fB:wK nB[;ko e/; :'r gkfJnk frnk j?.

gVskb fog'oN w[skfpe fJj e/; xZN T[wo$ tZX nkwdB$ tZX iwhB ekoB n:'r gkfJnk frnk.
e/; wzBi{oh$ oZd fjZs g/P j? ih.

vhfbzr eboe$ ;jkfJe

fwsh

;[govzN

fibQk ;wkfie ;[oZfynk nc;o

;w/s w'jo$ fwsh

_____________________________________________________________________________
gksosk

fJ; ;ehw nXhB 58 ;kb iK fJ; s' tZX T[wo dhnK n"osK, 65 ;kb iK fJ; s' tZX T[wo d/ g[o;a fiBQK dh nkwdB
2000$^ o[gJ/ fJZeb/ ns/ gsh^gsBh d't/A fizdk j'D dh ;{os ftZu 3000$^ o[gJ/ gqsh wjhBk s'A tZX Bk j't/.

fpB?eko fi; e'b tZX s'A tZX 2 J/eV Bfjoh$ukjh iwhB iK tZX s'A tZX 4 J/eV pokBh iwhB dh wkbeh j't/ (gsh gsBh d'Bk
B{z fwbk e/) ns/ T[; dh nkwdBh T[;d/ j'o ;kXBK B{z fwbk T[es do;kJh rJh nkwdB Bkb'A finkdk Bk j't/.

f;ckoP$ s;dhe
g/Av{ y/soK ftZu noIh ckow T[Zs/ f;ckoP$s;dhe eoB bJh j/m fby/ nj[d/dko nfXekos jBL^
;ogzu ns/ fJZe w?Apo gzukfJs
iK
fJZe Bzpodko ns/ fJZe w?Apo gzukfJs
iK
d' w?Apo gzukfJs
iK
u/nogo;B$w?Apo pbke ;zwsh ns/ fJZe w??Apo gzukfJs
iK
u/nogo;B$w?Apo fibQk gqhPd ns/ fJZe w?Apo gzukfJs

Pfjoh y/soK ftZu fwT[A;gb e"A;bo noih s;dhe$f;ckoP eoB bJh nfXekos j?.

e/; wzBi{o eoB dh ftXh

s;dhe$f;ckoP T[gozs fpB?ekoK d/ noIh ckow ;pzXs n?;HvhHn?wH d/ dcso tZb'A gqkgs ehs/ ikDr/.

;pzzXs n?;HvhHn?wH fJBQK s;dhe$f;ckoP d/ nXko s/ T[jBQK B{z nkoIh g?BPB wzBi{o eoB d/ nfXekos j'Dr/. fJ; ;pzXh
T[g wzvb nc;o ckow gqkgs j'D s/ fszB fdBQK d/ nzdo^nzdo gq'thIBb g?BPB wzBi{o eoBr/.

i/eo noIh ckow ;pzXs wjhB/ dh fwsh 1 sohy s'A 20 sohy sZe gqkgs j[zd/ jB sK g?BPB T[;/ wjhB/ fdZsh ikt/rh. fJ;
s'A pknd gqkgs j[zdk j? sK g?BPB nrb/ wjhB/ s'A bkr{ ehsh ikt/rh.

nkoIh g?BPB wzBi{o j'D s'A pknd ;kohnK noIhnK fibQk ;wkfie ;[oZf ynk nc;o B{z G/I fdZshnK ikDhnK :ehBh
pDkJhnK ikD. ;pzXs fibQk ;wkfie ;[oZfynk nc;o fJBQK noIh ckowK dh gVskb fJZe wjhB/ ftZu eoBh :ehBh
pDkT[Dr/ ns/ :'r gVskb eokT[D T[gozs i/eo bkGgksoh :'r gkfJnk iKdk j? sK g?BPB dh wzBi{oh gZeh ehsh ikt/rh.

i/eo gVskb d"okB e'Jh bkGgksoh n:'r gkfJnk iKdk j? sK ;pzXs f;ckoP$s;dhe eosk gk;'A bkGgksoh tZb'A gqkgs
ehsh okPh dh d[ZrDh okPh t;{b ehsh ikt/rh. fJj t;{bh G'A wkbhnk J/ohno tZi'A ehsh ikt/rh.

Simplified Proforma for Services under RTS Act. Service No. 96 (a) and (b) ckow
FAWD (ftXtk ns/ fBnk;fos n"osK B{z ftZsh ;jkfJsk)

BzH ;H;H^II

Photo of
Applicant
fpB?eko dh
c'N'
1.

Name of the Service/ ;/tk dk y/so

2.

Name of Applicant/ fpB?eko dk Bkw

3.

Name of Father/ fgsk dk Bkw

4.

Name of Husband/ gsh dk Bkw

5.

Age of Applicant/ fpB?eko dh T[wo

6.

Widow/ Destitute/ ftXtk$fBnk;fos

7.

Date of Death of Husband in case of widow

i/eo ftXtk j? sK gsh dh w"s dh fwsh
Date of MISSING OF Husband in case of destitute
in case of destitute due to missing of husband
Percentage of disability of Husband in case of
destitute due to of Husbands disability
Permanent Address/ gZek gsk

8.
9.
10.

11.

12.
13.
14.
15.
16.
17.
18.
19.

Rural / Urban Area

Correspondence Address/
gZso ftjko bJh gsk
Phone No./Mobile No.
c'B BzH$ w'pkfJb BzH
Correspondence e-mail/
JhHw/b nkJhHvhH
Aadhaar card No. (Attach Copy)
BPL No./ rohph o/yk s'A j/mK dh ;{uh dk BzH (ekgh BZEh)
SC/BC/ GEN
n?;H;hH$ phH;hH$ iBob
Husband/Wife alive or not?
eh gsh$gsBh fizdk j?<
Monthly Income from all sources
;ko/ t;hfbnK s'A wkf;e nkwdB
1Agriculture land ( Chahi/baraani)
5tkjh:'r iwhB (ukjh$pokBh)
.

20. 1Bank Detail / p?Ae dk t/otk

6
.

Name of bank

Name of Branch

Account No.

IFSC Code

w?A x'PDk eodh jK fe w/o/ tZb'A fdZsh rJh T[go'es ikDekoh ;jh tk do[;s j? ns/ e'Jh th sZE S[gkfJnk Bjh
frnk, i/eo fJj ;{uBK rbs gkJh iKdh j? sK w?A ;Ik dh Gkrhdko j'tKrh.
(Signature of Applicant)
fpB?eko d/ j;skyo
Sr.
No.

Required Document/ b'VhAd/ d;skt/I

1.

Voter Card or Voter List or Ration Card or Matriculation Certificate or Certificate from
Registrar Birth & Death As Age Proof (any one proof out of above) t'No ekov iK t'No ;{uh iK
okPB ekov iK d;thA dk ;oNhfce/N iK ofi;Noko iBw ns/ w"s tZb'A ikoh ;oNfce/N (ftZu'A e'Jh fJZe
iBw d/ ;p{s tZi'A )
i/eo n"os ftXtk j? sK gsh dh w"s dk ;oNhfce/N, i/eo gsh ngzr j'D ekoB o'Ih o'Nh ewkT[D s'A
n;woZE j? sK ;woZE nfXekoh tZb'A ikoh ehsk ngzrsk ;oNhfce/N BZEh ehsk ikt/ .

2.

Attached
copy/ ekgh
BZEh

iwhB ;pzXh fog'oN

s;dhe ehsk iKdk j? fe Pqh$Pqhwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHHHg[Zso$gsBh HHHHHHHHHHHHHHHHHHHHHtk;h HHHHHHHHHHHHHHHHd/ Bkw
wkb foekov nB[;ko HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHJ/eV (ukjh$pokBh) tkjh:'r iwhB j?.
(gNtkoh d/ j;skyo)
s;dhe f;ckoP eosk d/ j;skyo (;w/s w'jo)

ubdk gzBkHHHH2

^2^

T[g wzvb w?fi;No/N dcso dh tos'A bJh

fJj fpB?^gZso dcso d/ vkfJoh Bzpo HHHHHHHHHHHHHHHHHHHHHHHHHfwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHokjhA gqkgs j'fJnk, tkfunk frnk,
tkuD T[gozs fB:wK$jdkfJsK nB[;ko fJj fpB?eko g?BPB$ftZsh ;jkfJsk bJh :'r gkfJnk frnk j?.

fpB?eko n:'r gkfJnk frnk j?, feT[Afe T[wo xZN j?$ nkwdB tZX j?$iwhB tZX j?.
gq'thIBb g?BPB wzBi{o eoB$ oZd fjZs g/P j?.

vhfbzr eboe$ ;jkfJe

fwsh

T[g wzvb w?fi;No/N

;w/s w'jo$fwsh

fibQk ;wkfie ;[oZfynk nc;o dcso dh tos'A bJh

fJ; e/; dh gVskb eotkJh rJh, gVskb fog'oN$ fB:wK nB[;ko e/; :'r gkfJnk frnk j?.

gVskb fog'oN w[skfpe fJj e/; xZN T[wo$ tZX nkwdB$ tZX iwhB ekoB n:'r gkfJnk frnk.
e/; wzBi{oh$ oZd fjZs g/P j? ih.

vhfbzr eboe$ ;jkfJe

fwsh

;[govzN

fibQk ;wkfie ;[oZfynk nc;o

;w/s w'jo$ fwsh

_____________________________________________________________________________
gksosk

fJ; ;ehw nXhB 58 ;kb s' xZN T[wo dhnK ftXtktK$ fBnk;afos n"osK, 30 ;kb s' tZX T[wo dh
nDftnkjhnK fJ;sohnK bJh fiBQK dh nkwdB ;ko/ t;hfbnK s' 1000$^ o[gJ/ gqsh wjhBk s' tZX Bk j't/ B{z
ftZsh ;jkfJsk wzBi{o ehsh iKdh j?.

f;ckoP$ s;dhe
g/Av{ y/soK ftZu noIh ckow T[Zs/ f;ckoP$s;dhe eoB bJh j/m fby/ nj[d/dko nfXekos jBL^
;ogzu ns/ fJZe w?Apo gzukfJs
iK
fJZe Bzpodko ns/ fJZe w?Apo gzukfJs
iK
d' w?Apo gzukfJs
iK
u/nogo;B$w?Apo pbke ;zwsh ns/ fJZe w??Apo gzukfJs
iK
u/nogo;B$w?Apo fibQk gqhPd ns/ fJZe w?Apo gzukfJs

Pfjoh y/soK ftZu fwT[A;gb e"A;bo noih s;dhe$f;ckoP eoB bJh nfXekos j?.

e/; wzBi{o eoB dh ftXh

s;dhe$f;ckoP T[gozs fpB?ekoK d/ noIh ckow ;pzXs n?;HvhHn?wH d/ dcso tZb'A gqkgs ehs/ ikDr/.

;pzzXs n?;HvhHn?wH fJBQK s;dhe$f;ckoP d/ nXko s/ T[jBQK B{z nkoIh g?BPB wzBi{o eoB d/ nfXekos j'Dr/. fJ; ;pzXh
T[g wzvb nc;o ckow gqkgs j'D s/ fszB fdBQK d/ nzdo^nzdo gq'thIBb g?BPB wzBi{o eoBr/.

i/eo noIh ckow ;pzXs wjhB/ dh fwsh 1 sohy s'A 20 sohy sZe gqkgs j[zd/ jB sK g?BPB T[;/ wjhB/ fdZsh ikt/rh. fJ;
s'A pknd gqkgs j[zdk j? sK g?BPB nrb/ wjhB/ s'A bkr{ ehsh ikt/rh.

nkoIh g?BPB wzBi{o j'D s'A pknd ;kohnK noIhnK fibQk ;wkfie ;[oZfynk nc;o B{z G/I fdZshnK ikDhnK :ehBh
pDkJhnK ikD. ;pzXs fibQk ;wkfie ;[oZfynk nc;o fJBQK noIh ckowK dh gVskb fJZe wjhB/ ftZu eoBh :ehBh
pDkT[Dr/ ns/ :'r gVskb eokT[D T[gozs i/eo bkGgksoh :'r gkfJnk iKdk j? sK g?BPB dh wzBi{oh gZeh ehsh ikt/rh.

i/eo gVskb d"okB e'Jh bkGgksoh n:'r gkfJnk iKdk j? sK ;pzXs f;ckoP$s;dhe eosk gk;'A bkGgksoh tZb'A gqkgs
ehsh okPh dh d[ZrDh okPh t;{b ehsh ikt/rh. fJj t;{bh G'A wkbhnk J/ohno tZi'A ehsh ikt/rh.

Simplified Proforma for Services under RTS Act. Service No. 102 & 103
FADC (nkPfos pZfunK B{z ftZsh ;jkfJsk)

ckow BzH ;H;H^III

Photo of
Applicant
fpB?eko dh c'N'

1.

Name of the Service/ ;/tk dk y/so

2.

Name of Applicant/ fpB?eko dk Bkw

3.

Name of Father fgsk dk Bkw

4.

Name of Husband gsh dk Bkw

5.

Age of Applicant/ fpB?eko dh T[wo

6.

Widow/ Destitute ftXtk$fBnk;fos

7.

Date of Death of Husband in case of widow

Rural / Urban Area

i/eo ftXtk j? sK gsh dh w"s dh fwsh

8.

Date of Missing of Husband in case of destitute in

case of destitute due to missing of husband

9.

Percentage of disability of Husband in case of

destitute due to of Husbands disability

10.
11.
12.
13.
14.
15.
16.
17.
18.

19.

Permanent Address/ gZek gsk

Correspondence Address/
gZso ftjko bJh gsk
Phone No./Mobile No.
c'B BzH$ w'pkfJb BzH
Correspondence e-mail/
JhHw/b nkJhHvhH
Aadhaar card No. (Attach Copy)
BPL No./ rohph o/yk s'A j/mK dh ;{uh dk BzH (ekgh BZEh)
SC/BC/ GEN
n?;H;hH$ phH;hH$ iBob
Monthly Income from all sources
;ko/ t;hfbnK s'A wkf;e nkwdB
1Agriculture land ( Chahi/baraani)
5tkjh:'r iwhB (ukjh$pokBh)
.
Particular of Children

20. 1Bank Detail / p?Ae dk t/otk

6
.

Sr. No.

Name of bank

Name

Name of
Branch

DOB

Male /Female

Account No.

IFSC Code

w?A x'PDk eodh jK fe w/o/ tZb'A fdZsh rJh T[go'es ikDekoh ;jh tk do[;s j? ns/ e'Jh th sZE S[gkfJnk Bjh frnk, i/eo
fJj ;{uBK rbs gkJh iKdh j? sK w?A ;Ik dh Gkrhdko j'tKrh.
(Signature of Applicant)
fpB?eko d/ j;skyo
Sr. No.

Required Document/ b'VhAd/ d;skt/I

1.

Voter Card or Voter List or Ration Card or Matriculation Certificate or Certificate from
Registrar Birth & Death As Age Proof (any one proof out of above) t'No ekov iK t'No ;{uh iK
okPB ekov iK d;thA dk ;oNhfce/N iK ofi;Noko iBw ns/ w"s tZb'A ikoh ;oNfce/N (ftZu'A e'Jh fJZe
iBw d/ ;p{s tZi'A )

2.

i/eo pZu/ d/ fgsk dh w"s j' u[Zeh j? sK w"s dk ;oNhfce/N,i/eo fgsk ngzr j'D ekoB o'Ih o'Nh
ewkT[D s'A n;woZE j? sK ;woZE w?vheb nc;o tZb'A ikoh ;oNhfce/N BZEh ehsk ikt/.
fiBQK 2 pZfunK bJh ftZsh ;jkfJsk ukj[zd/ j' T[BK d/ iBw dk ;p{s BZEh ehsk ikt/.

3.

Attached copy/
ekgh BZEh

iwhB ;pzXh fog'oN

s;dhe ehsk iKdk j? fe Pqh$Pqhwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHHHg[Zso$gsBh HHHHHHHHHHHHHHHHHHHHHtk;h HHHHHHHHHHHHHHHHd/ Bkw
wkb foekov nB[;ko HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHJ/eV (ukjh$pokBh) tkjh:'r iwhB j?.

(gNtkoh d/ j;skyo)
s;dhe f;ckoP eosk d/ j;skyo (;w/s w'jo)

ubdk gzBkHHHH2

^2^

T[g wzvb w?fi;No/N dcso dh tos'A bJh

fJj fpB?^gZso dcso d/ vkfJoh Bzpo HHHHHHHHHHHHHHHHHHHHHHHHHfwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHokjhA gqkgs j'fJnk, tkfunk frnk,
tkuD T[gozs fB:wK$jdkfJsK nB[;ko fJj fpB?eko g?BPB$ftZsh ;jkfJsk bJh :'r gkfJnk frnk j? .

fpB?eko n:'r gkfJnk frnk j?, feT[Afe T[wo xZN j?$ nkwdB tZX j?$iwhB tZX j?.
gq'thIBb g?BPB wzBi{o eoB$ oZd fjZs g/P j?.

vhfbzr eboe$ ;jkfJe

fwsh

T[g wzvb w?fi;No/N

;w/s w'jo$fwsh

fibQk ;wkfie ;[oZfynk nc;o dcso dh tos'A bJh

fJ; e/; dh gVskb eotkJh rJh, gVskb fog'oN$ fB:wK nB[;ko e/; :'r gkfJnk frnk j?.

gVskb fog'oN w[skfpe fJj e/; xZN T[wo$ tZX nkwdB$ tZX iwhB ekoB n:'r gkfJnk frnk.
e/; wzBi{oh$ oZd fjZs g/P j? ih.

vhfbzr eboe$ ;jkfJe

fwsh

;[govzN

fibQk ;wkfie ;[oZfynk nc;o

;w/s w'jo$ fwsh

_____________________________________________________________________________
gksosk
U)

fJ; ;ehw nXhB 21 ;kb s'A xZN T[wo d/ nfij/ pZu/, fijV/ wkfgnK dh fJwdkd iK wksk^fgsk dh fwos{ j' ikD ekoD iK xo
s'A brksko wksk^fgsk dh r?o jkioh ekoD iK T[BQK dh ;aohoe $wkBf;e ngzrsk ekoD d/y Gkb s' tzfus j' rJ/ j'D, wkbh
;jkfJsk d/ gkso j'Dr/, p;aos/ fe wksk iK fgsk dh wkf;e nkwdB 1000$^ o[gJ/ gqsh wjhBk ns/ i/ wksk^fgsk d't/A fiT[Ad/
j'D sk T[BQK dh wkf;e nkwdB 1500$^ o[gJ/ gqsh wjhBk sA' tZX Bk j't/. gqsh gfotko B{z nkwdB dh ;aos nXhB 300$^ o[gJ/
gqsh pZuk gqsh wjhBk dh S'N j?, i' 2 pZfunk sZe ;hfws j't/rh. wksk fgsk d/ fiT[Ad/ Bk j'D dh ;{os ftu shi/ pZu/ B{z th
gqpzXeh ftGkr dh gqtkBrh T[gozs ftZsh ;jkfJsk fdZsh ik ;edh j?.

n)

nk;afos pZfunK B{z ftZsh ;jkfJsk ;ehw d/ e/;K ftZu wksk ^fgsk$ rkovhnB dh w"s j' ikD dh ;{os ftZu ;pzXs wzBi{oh eosk
nfXekoh$n?;HvhHn?w tb'A fe;/ Bidhe fo;s/dko dh ps"o rkovhnB$tko; Bkwiadrh ehsh ikt/rh. g[okD/ noih ckow ns/
g[okD/ ghHn?bH J/H BzL T[s/ jh Bt/ Bkwiad rkovhnB$tko;

dh gqtkBrh wzBi{o eosk nfXekoh tZb' fdZsh ikt/rh ns/ ftZsh

;jkfJsk Bkwiad ehs/ rJ/ rkovhnB$tko; d/ BK s/ fpBQk o'e/ ikoh oZyh ikt/rh.

f;ckoP$ s;dhe
g/Av{ y/soK ftZu noIh ckow T[Zs/ f;ckoP$s;dhe eoB bJh j/m fby/ nj[d/dko nfXekos jBL^
;ogzu ns/ fJZe w?Apo gzukfJs
iK
fJZe Bzpodko ns/ fJZe w?Apo gzukfJs
iK
d' w?Apo gzukfJs
iK
u/nogo;B$w?Apo pbke ;zwsh ns/ fJZe w??Apo gzukfJs
iK
u/nogo;B$w?Apo fibQk gqhPd ns/ fJZe w?Apo gzukfJs

Pfjoh y/soK ftZu fwT[A;gb e"A;bo noih s;dhe$f;ckoP eoB bJh nfXekos j?.

e/; wzBi{o eoB dh ftXh

s;dhe$f;ckoP T[gozs fpB?ekoK d/ noIh ckow ;pzXs n?;HvhHn?wH d/ dcso tZb'A gqkgs ehs/ ikDr/.
;pzzXs n?;HvhHn?wH fJBQK s;dhe$f;ckoP d/ nXko s/ T[jBQK B{z nkoIh g?BPB wzBi{o eoB d/ nfXekos j'Dr/. fJ; ;pzXh
T[g wzvb nc;o ckow gqkgs j'D s/ fszB fdBQK d/ nzdo^nzdo gq'thIBb g?BPB wzBi{o eoBr/.

i/eo noIh ckow ;pzXs wjhB/ dh fwsh 1 sohy s'A 20 sohy sZe gqkgs j[zd/ jB sK g?BPB T[;/ wjhB/ fdZsh ikt/rh. fJ; s'A
pknd gqkgs j[zdk j? sK g?BPB nrb/ wjhB/ s'A bkr{ ehsh ikt/rh.

nkoIh g?BPB wzBi{o j'D s'A pknd ;kohnK noIhnK fibQk ;wkfie ;[oZfynk nc;o B{z G/I fdZshnK ikDhnK :ehBh pDkJhnK
ikD. ;pzXs fibQk ;wkfie ;[oZfynk nc;o fJBQK noIh ckowK dh gVskb fJZe wjhB/ ftZu eoBh :ehBh pDkT[Dr/ ns/ :'r
gVskb eokT[D T[gozs i/eo bkGgksoh :'r gkfJnk iKdk j? sK g?BPB dh wzBi{oh gZeh ehsh ikt/rh.

i/eo gVskb d"okB e'Jh bkGgksoh n:'r gkfJnk iKdk j? sK ;pzXs f;ckoP$s;dhe eosk gk;'A bkGgksoh tZb'A gqkgs ehsh
okPh dh d[ZrDh okPh t;{b ehsh ikt/rh. fJj t;{bh G'A wkbhnk J/ohno tZi'A ehsh ikt/rh.

Simplified Proforma for Services under RTS Act. Service No. 96 (a) and (b)
FADP (ngzr ftneshnK B{z ftZsh ;jkfJsk)

ckow BzH ;H;H^IV

Photo of
Applicant
fpB?eko dh
c'N'

1.

Name of the Service/ ;/tk dk y/so

2.

Name of Applicant/ fpB?eko dk Bkw

3.

Name of Father fgsk dk Bkw

4.

Name of Husband gsh dk Bkw

5.

Age of Applicant/ fpB?eko dh T[wo

6.

Percentage of disability/ ngzrsk dh gaqshPssk

7.

Permanent Address/ gZek gsk

8.

Correspondence Address/
gZso ftjko bJh gsk

9.

Phone No./Mobile No.

c'B BzH$ w'pkfJb BzH
Correspondence e-mail/
JhHw/b nkJhHvhH
Aadhaar card No. (Attach Copy)
BPL No./ rohph o/yk s'A j/mK dh ;{uh dk BzH (ekgh
BZEh)
SC/BC/ GEN
n?;H;hH$ phH;hH$ iBob
Monthly Income from all sources
;ko/ t;hfbnK s'A wkf;e nkwdB
Agriculture land ( Chahi/baraani)
tkjh:'r iwhB (ukjh$pokBh)

10.
11.
12.
13.
14.
15.

16.

Particular of Children

Sr. No.

17. 1Bank Detail / p?Ae dk t/otk

6
.

ngzrsk ;pzXh w?vheb ;oNhfce/N

Rural / Urban Area

Name of bank

Name

Name of
Branch

DOB

Male /Female

Account No.

IFSC Code

s;dhe ehsk iKdk j? fe Pqh$Pqhwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHg[Zso$g[Zsoh$gsBhHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHT[go'es dZ;/

gs/ dk ofjD tkbk $ ofjD tkbh j? ns/ T[j HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHfpwkoh$u'N bZrD ekoB HHHHHHHHHHH # ngzr j?.

fJj ;oNhfce/N w?vheb nc;o, I' ghH;hHn?wHn?;H s'A xZN Bk j't/ tZb'A fdZsk ikt/rk.

w?vheb nc;o d/ j;skyo (;w/s w'jo)

w?A x'PDk eodk$eodh jK fe w/o/ tZb'A fdZsh rJh T[go'es ikDekoh ;jh tk do[;s j? ns/ e'Jh th sZE S[gkfJnk Bjh frnk,
i/eo fJj ;{uBK rbs gkJh iKdh j? sK w?A ;Ik dk Gkrhdko j'tKrk$j'tKrh.
(Signature of Applicant)
fpB?eko d/ j;skyo
Sr. No.

Required Document/ b'VhAd/ d;skt/I

1.

Voter Card or Voter List or Ration Card or Matriculation Certificate or Certificate from
Registrar Birth & Death As Age Proof (any one proof out of above) t'No ekov iK t'No ;{uh iK
okPB ekov iK d;thA dk ;oNhfce/N iK ofi;Noko iBw ns/ w"s tZb'A ikoh ;oNfce/N (ftZu'A e'Jh fJZe
iBw d/ ;p{s tZi'A )

Attached copy/
ekgh BZEh

iwhB ;pzX fog'oN

s;dhe ehsk iKdk j? fe Pqh$Pqhwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHHHg[Zso$gsBh HHHHHHHHHHHHHHHHHHHHHtk;h HHHHHHHHHHHHHHHHd/ Bkw
wkb foekov nB[;ko HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHJ/eV (ukjh$pokBh) tkjh:'r iwhB j?.
(gNtkoh d/ j;skyo)
s;dhe f;ckoP eosk d/ j;skyo (;w/s w'jo)

ubdk gzBkHHHH2

^2^

T[g wzvb w?fi;No/N dcso dh tos'A bJh

fJj fpB?^gZso dcso d/ vkfJoh Bzpo HHHHHHHHHHHHHHHHHHHHHHHHHfwsh HHHHHHHHHHHHHHHHHHHHHHHHHHHokjhA gqkgs j'fJnk, tkfunk frnk,
tkuD T[gozs fB:wK$jdkfJsK nB[;ko fJj fpB?eko g?BPB$ftZsh ;jkfJsk bJh :'r gkfJnk frnk j? .

fpB?eko n:'r gkfJnk frnk j?, feT[Afe T[wo xZN j?$ nkwdB tZX j?$iwhB tZX j?.
gq'thIBb g?BPB wzBi{o eoB$ oZd fjZs g/P j?.

vhfbzr eboe$ ;jkfJe

fwsh

T[g wzvb w?fi;No/N

;w/s w'jo$fwsh

fibQk ;wkfie ;[oZfynk nc;o dcso dh tos'A bJh

fJ; e/; dh gVskb eotkJh rJh, gVskb fog'oN $ fB:wK nB[;ko e/; :'r gkfJnk frnk j?.

gVskb fog'oN w[skfpe fJj e/; xZN T[wo$ tZX nkwdB$ tZX iwhB ekoB n:'r gkfJnk frnk.
e/; wzBi{oh$ oZd fjZs g/P j? ih.

vhfbzr eboe$ ;jkfJe

fwsh

;[govzN

fibQk ;wkfie ;[oZfynk nc;o

;w/s w'jo$ fwsh

_____________________________________________________________________________
gksosk
U)

fJ; ;ehw nXhB B/sojhD, ;ohoe s"o s/ ngzr, r[zr/ p'b/, xZN fdwkr tkb/ iK rzGho fpwkoh ekoD ngzr j' rJ/
ftnesh, ftZsh ;jkfJsk b?D d/ gkso j'Dr/.
50# s' xZN ngzrsk tkb/ ftnesh wkbh ;jkfJsk bJh :'r BjhA j'Dr/.
wzd^p[ZXh ekoD ngzr ftneshnK bJh wkbh ;jkfJsk tk;s/ xZN s'A xZN ngzrsk dh e'Jh gqsh;aZssk fB;afus BjhA j?.
fpB?eko dh nkgDh nkwdB 1000$^ o[gJ/ gqsh wjhBk ns/ i/eo fpB?eko ;akdh ;aa[dk j? sK d'jK dh nkwdB 1500$^ o[gJ/
gqsh wjhBk s' tZX Bk j't/.
i/eo ngzr ftnesh y[Zd ewkT{ Bk j't/ sK wkfgnK dh nkwdB i/eo T[BQK dk fJZe pZuk j't/ sK 2500$^o[gJ/ gqsh wjhBk sZe
;hfws j't/rh ns/ i/ d' iK T[; s' tZX pZu/ j'D sK nkwdB gqsh wjhBk 3000$^ o[gJ/ sZe frDh ikt/rh.
xZN fdwkr tkb/ iK wkBf;e s"o s/ fpwko ftneshnK iK 21 ;kb s' xZN T[wo d/ ngzr pZfunK B{z ftZsh ;jkfJsk ;ehw d/
e/; ftZu wksk^ fgsk$gsh^gsBh$ rkovhnB dh w"s j' ikD dh ;{os ftZu ;pzXs wzBi{oh eosk nfXekoh$n?;HvhHn?w tb'A
fe;/ Bidheh fo;s/dko dh ps"o rkovhnB$tko;a Bkwiadrh ehsh ikt/rh. g[okD/ noih ckow ns/ ghHn?bHJ/HBzL T[s/ jh Bt/
Bkwiad rkovhnB$tko;a Bz{ ftZsh ;jkfJsk fpBQk o'e/ ikoh oZyh ikt/rh.wksk^fgsk$gsh^gsBh $ rkovhnB dh w"s j' ikD d/
ekoB xZN fdwkr tkb/ iK wkBf;e s"o s/ ngzr$ fpwko ftneshnK iK 21 ;kb s'A xZN T[wo d/ ngzr pZfunK d/ e/; ftZu
tko; dh nkwdB BjhA ftukoh ikt/rh.

n)
J)
;)
j)
e)

f;ckoP$ s;dhe

g/Av{ y/soK ftZu noIh ckow T[Zs/ f;ckoP$s;dhe eoB bJh j/m fby/ nj[d/dko nfXekos jBL^
;ogzu ns/ fJZe w?Apo gzukfJs
iK
fJZe Bzpodko ns/ fJZe w?Apo gzukfJs
iK
d' w?Apo gzukfJs
iK
u/nogo;B$w?Apo pbke ;zwsh ns/ fJZe w??Apo gzukfJs
iK
u/nogo;B$w?Apo fibQk gqhPd ns/ fJZe w?Apo gzukfJs

Pfjoh y/soK ftZu fwT[A;gb e"A;bo noih s;dhe$f;ckoP eoB bJh nfXekos j?.

e/; wzBi{o eoB dh ftXh

s;dhe$f;ckoP T[gozs fpB?ekoK d/ noIh ckow ;pzXs n?;HvhHn?wH d/ dcso tZb'A gqkgs ehs/ ikDr/.

;pzzXs n?;HvhHn?wH fJBQK s;dhe$f;ckoP d/ nXko s/ T[jBQK B{z nkoIh g?BPB wzBi{o eoB d/ nfXekos j'Dr/. fJ; ;pzXh
T[g wzvb nc;o ckow gqkgs j'D s/ fszB fdBQK d/ nzdo^nzdo gq'thIBb g?BPB wzBi{o eoBr/.

i/eo noIh ckow ;pzXs wjhB/ dh fwsh 1 sohy s'A 20 sohy sZe gqkgs j[zd/ jB sK g?BPB T[;/ wjhB/ fdZsh ikt/rh. fJ;
s'A pknd gqkgs j[zdk j? sK g?BPB nrb/ wjhB/ s'A bkr{ ehsh ikt/rh.

nkoIh g?BPB wzBi{o j'D s'A pknd ;kohnK noIhnK fibQk ;wkfie ;[oZfynk nc;o B{z G/I fdZshnK ikDhnK :ehBh
pDkJhnK ikD. ;pzXs fibQk ;wkfie ;[oZfynk nc;o fJBQK noIh ckowK dh gVskb fJZe wjhB/ ftZu eoBh :ehBh
pDkT[Dr/ ns/ :'r gVskb eokT[D T[gozs i/eo bkGgksoh :'r gkfJnk iKdk j? sK g?BPB dh wzBi{oh gZeh ehsh ikt/rh.

i/eo gVskb d"okB e'Jh bkGgksoh n:'r gkfJnk iKdk j? sK ;pzXs f;ckoP$s;dhe eosk gk;'A bkGgksoh tZb'A gqkgs
ehsh okPh dh d[ZrDh okPh t;{b ehsh ikt/rh. fJj t;{bh G'A wkbhnk J/ohno tZi'A ehsh ikt/rh.

Subject: -

Simlification performa for Service under RTS Act; -regarding Old Age
Pension and Financial Assistance Scheme.
________
ftuko nXhB gZso BzH PSe GS/SM/e- District /2014/19/3395 dated 18/5/16

i' vkfJo?eNo, rtoB?A; fockowI ftGkr gzikp tZb'A gkqgs j'fJnk j?, tkuD fjZs ih.
fJ; gZso okjhA ftGkr d/ gZso Bzpo 15881 fwsh 12H5H16 okjhA rtoB?A;
fockowI ftGkr B{z G/i/ rJ/ p[Ykgk g?BPB, ftXtk ns/ fBnk;fos n"osK B{z ftZsh ;jkfJsk,
nkPfos pZfunK B{z ftZsh ;jkfJsk ns/ ngzr ftneshnK B{z ftZsh ;jkfJsk d/ ckowK ftZu e[M
nzfPe ;'XK fit/A fe Bank Account ns/ IFSC Code d/ Bkb Bkb p?Ae dk g{ok Bkw ns/ p?Ae
poKu dk g{ok Bkw doI eoB bJh fejk frnk j?.
fJ; ;pzX ftZu dZf;nk iKdk j? fe ftGkr tZb'A g?BPB ;ehwK nXhB fsnko
ehs/ noIh ckow I' B'fNzr gzBk^5 s/ gqw[Zy ;eZso, ;wkfie ;[oZfynk ih tZb'A gqtkB ehs/ rJ/
jB, vkfJo?eNo rtoB?A; fockowI ftGkr B{z G/i/ rJ/ ;B.vkfJo?eNo rtoB?A; ftGkr tZb'A
jtkbk nXhB gZso okjhA ehshnK rJhnK ;'XK w?B{nb ckowK ftZu bkr{ eoB dh ;bkj fdZsh
rJh j?.
wkB:'r w[Zy wzsoh gzikp ih dh gqXkBrh j/m fwsh 18H05H2016 B{z j'Jh whfNzr
;w/A ftGkr tZb'A fsnko ehs/ g?BPB ckow fifbQnK B{z G/iD d/ j[ew fdZs/ rJ/ jB ns/ fJBQK
dh ekgh gqw[Zy ;eZso w[Zy wzsoh gzikp B{z G/iD bJh th fejk frnk j?.
dcso dh sIthI j? fe rtoB?A; ftGkr tZb'A ftuko nXhB gZso okjhA
;[MkJhnK rJhnK ;'XK T[gozs fsnko ehs/ noIh ckow I' j/mK oZy/ iKd/ jB, fifbQnK ftZu
G/I d/D/ ukjhd/ jB ns/ fJ;dh ekgh gqw[Zy ;eZso w[Zy wzsoh gzikp B{z :'r ;{uBK fjZs G/i
d/Dh :'r j't/rh.fJ; s'A fJbktk jkb dh xVh p[Ykgk g?BPB ;ehw nXhB 3 bZy ckow, ftXtk
n"osK B{z ftZsh ;jkfJsk ;ehw nXhB gqsh ;ehw 1 bZy ckow, nkPfos pZfunK B{z ftZsh
;jkfJsk nXhB 1 bZy ckow ns/ j?Avhe?gv ;ehw nXhB 1 bZy ckow SkgD bJh fgqfNzr ns/
;N/PBoh ftGkr B{z fby d/Dk ukjhdk j?.
fw;b gqw[Zy ;eZso, ;wkfie ;[oZfynk ih dh gqtkBrh fjZs g/P j? ih.

;zHvH(;;)