The Public information Officer
PIN: _______________________
Subject: Request for Information under Right to Information Act 2005.
I Sri / Smt /Ms. _____________________________________________
Son/Daughter/wife of Shri/Smt/Ms. _____________________________
resident of ________________________________________________,
telephone number (with STD Code) ____- _____________________ and/or mobile
number: ______________________________ wish to seek information as under
I hereby inform that following formalities have been completed by me:
1. That I have deposited the requisite fee of Rs. _____/- by way of Cash / banker
cheque / Draft / Postal Order/ others ___________________ ) favoring
__________________________________ dated ________________.
2. I need the photocopy of the documents and I had deposited the cost of the
photocopy of Rs. ____/- for _____ (Number of Pages)
3. I had deposited sum of Rs. _____/- for the charges of CD. (strike out which ever is not applicable)
4. That I belong to Category of below Poverty Line (BPL): Yes / No
(Strike whichever is not applicable). If yes, I am attaching the valid photocopy of the certificate. Yes / No
5. That I am ‘Citizen’ of India and I am asking the information as ‘Citizen’.
6. I assure that I shall not allow/ cause to use/ pass/share/display/ or circulate the information received in any case and under any circumstances, with any person or in any manner which would be detrimental to the Unity and Sovereignty or against the Interest of India.
Signature of the Applicant

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