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To
The Inspector Food & Supplies,
... Block, District
Sir,
I would like to request you to please exclude My name/ Name of my family member name from Rajya Khadya Suraksha Yojana (RKSY) / National Food Security Act (NFSA) List.
Block - Gram Panchayet Enumaration Block No.-
Village Samsad - Village - Mouza Mobile no. (of any family member) -
NFSA/RKSY card no Card type Name of Head of the Family Name of the other family member of State reason for exclusion from the NFSA/RKSY list
(AAY/PHH/ the family who possesses the card of mentioned in reverse page.
SPHH/ NFSA / RKSY
RKSY-I/
RKSY-II etc.)
*If surrender application submitted due to death of any family member, please mention date of death. Submission of death registration certificate is mandatory.
____________________
Signature of Applicant
__________________________