FORM OF APPLICATION MAKING REQUEST FOR INFORMATION (Under the Provisions of the RTI Act, 2005) To. The State Public Information Officer Assistant Public Information Officer _____________________________ (Name of Officer) _____________________________ (Name of Department) Public Authority 1. Name with father's / mother's or : husband's name of the person making request for information. 2. Address of communication with : phone no. if any? 3. Whether citizen of India? : 4. Whether living below poverty line, if : so, Card No. 5. Nature of information / sample / : model / materials / to be provided. 6. Mode of delivery : 7. Advance fee, if any paid : Application fee Further fee, if any : Total : 8. Name of any person other than the : applicant whose assistance may be required for seeking the information / inspection. 9. Date of application : ____________________________ (Signature of the applicant) Date of assessment of cost Amount of fee / cost Date by which fee / cost to be deposited Actual date of payment of fee with receipt no. and date Date on which information is ready for supply Date of supply of information / samples etc. Signature of the person receiving the information / mode of supply 1 2 3 4 5 6 7 * If rejected, the reasons therefore with signature of the SPIO
