[ See Rule – 4 (I) ]

Application for information under section 6(1) of the Act.


The Public Information Officer

(Name of the Office with Address)

  1. Full name of the applicant
  2. Father/Spouse name
  3. Permanent address
  4. Particulars in respect of identity of the application
  5. Particulars of information solicited
    1. Subject matter of information
    2. The period to which of information relates
    3. Specific details of information required
    4. Whether information is required by post or in person (The actual postal charges shall be included in providing information)
    5. In case by post (ordinary, registered or Speed)
  6. Address to which information will be sent & in which form
  7. Has the information provided earlier
  8. Is this information not made available by the Public authority
  9. Do you agree to pay the required fee
  10. Have you deposited application fee
    (If yes details of such deposit)
  11. Whether belongs to BPL category, have you furnished the proof of the same.

Place                                                                                                      Full Signature of the applicant

Date                                                                                                                     Address

Office of the Public Information Officer

Received the application form ________________________________________ address _________________________________ ___________________________________________________________________ on ___________________ seeking information

Place                                                                                                  Full name of Public Information Officer

Date                                                                                                                Designation & Seal

1st Appellate Authority: Smt. Rasmita Rani Tarasia, OAS (SAG), Secretary

PIO: Mr. Ranjit Kumar Maharana, Administrative Officer

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RTI Information