SAMPLE RTI APPLICATION FORM

SAMPLE RTI APPLICATION FORM
Date

To,
The Public information Officer
________________________
____________________________
____________________________
PIN: _______________________


Sir,

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
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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)
or

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

Dated:

Form A

[See rule 3 (1)]
Date

To

The State Public Information Officer e.g. City Magistrate, D.C. Office, Rohtak, 124 001

1. Full name of the applicant: xxxxxxxxxx

2. Address: yyyyyyyy

3. Particulars of information required: - e.g. from Tehasildar Sale - Rohtak

(i) Subject matter of information e.g. “Displaced Persons (Compensation and Rehabilitation) Act, 1954 of Central Govt., Act No 44 of 1954”

(ii) The period to which the zz
information relates

(iii) Description of the XXXXXXXX

information required



(iv) Whether information is XXX
by post or in person

(v) In case by post Registered
(Ordinary, Registered or Speed)


Place: New Delhi (Signature of the Applicant)
Date:


Payment detail: e.g. Payment of Rs. 100/- (Rs. 50/- fee under RTI Act and Rs. 50/- for postal charges)

Encl: - e.g. Copy of Treasure Challan for Rs. 100/- No. Dated of SBI, Rohtak.

ACKNOWLEDGEMENT

Received your application dated _______________ ,
Vide Diary No.______________ dated _____________ .

(Signature)
e.g. City Magistrate, D.C. Office, Rohtak
State Public Information Officer/ Name of the Department/Office