# **e**q¶r vkSj **?k**V**s** ewY; ij Ldwyh ![](media/image1.png){width="1.0402777777777779in" height="1.2486111111111111in"}Hkkstu

vkosnu vkSj tkap QkWeZ

#  

# Ldwy o\"kZ \_\_\_\_\_-\_\_\_\_\_

# **L**dwy **ft**yksa **d**s fy, **fu**nsZ\'k 

bl iSdsV esa \'kkfey gSa%

**okafNr** tkudkjh ftls ?kj ds yksxksa dks miyC/k djkuk *t:jh* gS%

-   ?kj ds yksxksa dks i=

-   eq¶r vkSj ?kVs ewY; ij Ldwyh Hkkstu vkosnu&i=

;ksX;rk tkudkjh lkexzh dh tkap%

-   ;ksX;rk dh tkap ds fy, p;u dh vf/klwpuk

-   tkap ifj.kke dk i=

**oSdfYid** vkosnu&laca/kh lkexzh tks ?kj ds yksxksa dks iznku dh tk
*ldrh* gS%

-   esfMdsM@,llh,pvkbZih ds lkFk lgHkkxh tkudkjh

-   vU; dk;ZØeksa ds lkFk lgHkkxh tkudkjh

;s ist 8½" X 11" dkxt+ ij fizaV djus ds fy, fMtkbu fd, x, gSaA dqN
istksa ij vkxs&ihNs fizaV fd;k tk ldrk gSA vkidks vius Ldwy esa is\'k
fd, tkus okys ykHkksa dh igpku djus dh t:jr gksxh tSls Ldwy ds ckn feyus
okys LuSDlA **\[cM+k dks\"Bd {ks=\]** n\'kkZrk gS tgka vkidks Ldwy ftys
dh fo\'ks\"k tkudkjh \'kkfey djus dh t:jr gSA mnkgj.k ds fy,\] vkidks
tkap lkexzh ij tkap lgk;rk ds fy, vius ftys dk fu%\'kqYd VsfyQksu uacj
\'kkfey djuk t:jh gSA ;fn ;s lkefxz;ka t:jrean ifjokjksa dks vLFkkbZ
lgk;rk ¼Vh,,u,Q½\] jkT; ds cPpksa ds LokLF; chek dk;ZØe ¼,llh,pvkbZih½
;k ;fn ykxw gks\] Hkkjrh; vkjf{kr Hkkstu forj.k dk;ZØe ¼,QMhihvkbZvkj½
tksM+us ds fy, vkids jkT; dk uke \'kkfey djus ds fy, la\'kksf/kr ugha
gSa\] vkidks mfpr :i esa tkudkjh ntZ+ djuh pkfg,A ;fn vki vfrfjDr cnyko
djrs gSa\] vkidks vius vkosnu iSdst LohÑfr ds fy, viuhs jkT; ,tsalh ds
ikl tek djuk t:jh gSA

bl ewy:i vkosnu iSdst esa lSU; vkokl futhdj.k igy ds yksxksa ds fy, x\`g
HkÙkk vyx djus ds laca/k eas tkudkjh \'kkfey gSA ;fn ;g vkids Ldwy ftys
ls lac) ugha gS\] d\`i;k mfpr :i esa la\'kksf/kr djsaA

;fn vkidk dksbZ iz\'u gks\] laidZ djsa%

**\[State agency address\]**

**\[Insert School District Letterhead\]**

fiz; vfHkHkkod@laj{kd%

##### cPpksa dks lh\[kus ds fy, LokLF;o/kZd Hkkstu dh t:jr gksrh gSA \[Name of School\] izR;sd Ldwyh fnu esa LokLF;o/kZd Hkkstu is\'k djrk gSA uk\'rs dk ewY; \[\$\]; yap dk ewY; \[\$\]A vkids cPps eq¶r Hkkstu ;k ?kVs ewY; ij Hkkstu ds ik= gks ldrs gSaA uk\'rs ds fy, \[\$\] vkSj yap ds fy, \[\$\] ?kVk ewY; gSA

**1-** **D;k eq\>s izR;sd cPps ds fy, vkosnu Hkjus dh t:jr gS\\** ughaA
eq¶r vFkok ?kVs ewY; ij Hkkstu ds fy, vkosnu gsrq vkosnu QkWeZ HkjsaA
[vius ?kj ds lHkh fo\|kfFkZ;ksa ds fy, ,d eq¶r vkSj ?kVs ewY; ij Ldwy
Hkkstu vkosnu QkWeZ iz;ksx djsaA]{.underline} ge og vkosnu Lohdkj ugha
dj ldrs tks iw.kZ ugha gS\] blfy, lHkh okafNr tkudkjh Hkjuk lqfuf\'pr
djsaA **iw.kZ Hkjs vkosnu QkWeZ** **ykSVk,a% \[name, address, phone
number\].**

**2- eq¶r Hkkstu dkSu izkIr dj ldrk gS\\** QwM LVSai izkIr djus okys
?kjksa ds cPps ;k Vh,,u,Q vkSj T;knkrj ikfyr cPps vkidh vk; ij /;ku fn,
fcuk eq¶r Hkkstu izkIr dj ldrs gSaA vkids cPps rc Hkh eq¶r Hkkstu izkIr
dj ldrs gSa ;fn vkidh ?kjsyw vk; la?kh; vk; fn\'kkfunsZ\'k esa eq¶r lhek
ds varxZr gSA

**3- D;k cs?kj\] Hkkxs vkSj izoklh cPps eq¶r Hkkstu izkIr dj ldrs
gSa\\** ;g ns\[kus ds fy, fd vkids cPps ik= gSa\] d\`i;k **\[school,
homeless liaison or migrant coordinator\]** ls laidZ djsa\] ;fn vkidks
lwfpr ugha fd;k x;k fd mUgsas eq¶r Hkkstu feysxkA

**4- ?kVs ewY; ij dkSu Hkkstu izkIr dj ldrk gS\\** vkids cPps ?kVs ewY;
ij Hkkstu izkIr dj ldrs gSa ;fn vkidh ?kjsyw vk; bl vkosnu QkWeZ ij
çnf\'kZr la?kh; vk; pkVZ esa eq¶r lhek ds varxZr gSA

**5- ;fn eq\>s bl Ldwyh o\"kZ esa i= feyrk gS fd esjs cPps eq¶r vFkok
?kVs ewY; ij Hkkstu izkIr djus ds fy, LohÑr gSa\] eq\>s vkosnu QkWeZ
Hkjuk pkfg,\\** d\`i;k vkidks izkIr i= /;kuiwoZd i\<+s vkSj funsZ\'kksa
dk ikyu djsaA ;fn vkidk dksbZ iz\'u gks\] **\[phone number\]** ij Ldwy
ls laidZ djsaA

**6- eq\>s MCY;wvkbZlh feyrk gSA D;k esjs cPps eq¶r Hkkstu ys ldrs
gSa\\** MCY;wvkbZlh esa Hkkxhnkj ?kjksa ds cPps eq¶r vkSj ?kVs ewY; ij
Hkkstu ds ik= gks ldrs gSaA d\`i;k vkosnu QkWeZ HkjsaA

**7- D;k esjs }kjk nh xbZ tkudkjh tkaph tk,xh\\** gka\] ge vkils fyf\[kr
lcwr Hkstus ds fy, dg ldrs gSaA

**8- ;fn eSa vHkh ik= ugha gwa\] D;k eSa ckn esa vkosnu dj ldrk gwa\\**
gkaA vki Ldwyh o\"kZ ds nkSjku fdlh Hkh le; vkosnu dj ldrs gSa ;fn vkidk
dqVqEc c\<+rk gS\] vk; ?kVrh gS ;k ;fn vki QwM LVSai\] Vh,,u,Q ;k vU;
ykHk feyus \'kq: gks tkrs gSaA ;fn vkidh ukSdjh pyh tkrh gS\] vkids cPps
eq¶r ;k ?kVs ewY; ij Hkkstu ds ik= gks ldrs gSaA

**9- ;fn eSa vius vkosnu ds ckjs esa Ldwy ds fu.kZ; ls lger u gwa rks
D;k\\** vkidks Ldwy ds vf/kdkfj;ksa ls ckr djuh pkfg,A vki ;gka dkWydj
vFkok fy\[kdj lquokbZ ds fy, Hkh dg ldrs gSa% **\[name, address, phone
number\]**.

**10- ;fn esjs ?kj ds yksxksa esa ls dksbZ vesfjdh ukxfjd ugha gS\] D;k
eSa vkosnu dj ldrk gwa\\** gkaA eq¶r ;k ?kVs ewY; ij Hkkstu dh ik=rk ds
fy, vki ;k vkids cPpksa dk vesfjdh ukxfjd gksuk t:jh ugha gSA

**11- eq\>s vius ?kj ds lnL;ksa ds :i esa fdls \'kkfey djuk pkfg,\\**
vkidks vius ?kj esa jgus okys\] laca/kh gks ;k ugha\] lHkh dks \'kkfey
djuk t:jh gS\] ¼tSls nknk&nknh\] vU; laca/kh ;k fe=½A vkidks Lo;a dks
vkSj vius lkFk jgus okys lHkh cPpksa dks \'kkfey djuk t:jh gSA

**12- ;fn esjh vk; lnk ,d lh ugha jgrh rks D;k\\** og jkf\'k fy\[ksa tks
vki lkekU;r% ikrs gSaA mnkgj.k ds fy,\] ;fn vkidks gj ekg 1000 MkWyj
feyrs gSa\] ysfdu fiNys ekg vkidk dqN dke NwV x;k vkSj dsoy 900 MkWyj
feys\] rks fy\[ksa fd vki izfrekg 1000 MkWyj ikrs gSaA ;fn vkidks
lkekU;r% vksojVkbe feyrk gS\] mls \'kkfey djsa\] ysfdu ;fn vki dHkh&dHkh
feyrk gS rks u djsaA

**13- ge fefyVjh esa gSa\] D;k ge vkokl HkÙkk vk; ds :i esa \'kkfey
djsa\\** ;fn vkidk ?kj fefyVjh vkokl futhdj.k igy dk Hkkx gS\] viuk
vkokl HkÙkk vk; ds :i esa \'kkfey u djsaA vU; lHkh HkÙks vkidh ldy vk;
esa \'kkfey gksus t:jh gSaA\]

;fn vkidk vU; iz\'u vFkok enn dh t:jr gS\] **\[phone number\]** ij dkWy
djsa

*Si necesita ayuda, por favor llame al teléfono: **\[phone number\].***

*Si vous voudriez d'aide, contactez nous au numero: **\[phone
number\].***

Hkonh;\]

**\[signature\]**

**vkosnu djus ds fy, funZs\'k**

+-----------------------------------------------------------------------+
| **;fn vkids dqVqEc dks QwM LVSai vFkok Vh,,u,Q feyrk gS\] bu          |
| funsZ\'kksa dk ikyu djsa%**                                           |
|                                                                       |
| **Hkkx 1%** cPpksa ds uke\] Ldwy\] xzsM vkSj QwM LVSai vFkok Vh,,u,Q  |
| ekeyk la\[;k fy\[ksaA                                                 |
|                                                                       |
| **Hkkx 2%** mfpr ckWDl ij fu\'kku yxk,a\] ;fn dksbZ gksA              |
|                                                                       |
| **Hkkx 3%** ;g Hkkx NksM+ nsaA                                        |
|                                                                       |
| **Hkkx 4%** ;g Hkkx NksM+ nsaA                                        |
|                                                                       |
| **Hkkx 5%** QkWeZ ij gLrk{kj djsaA lkekftd lqj{kk la\[;k t:jh ugha    |
| gSA                                                                   |
|                                                                       |
| **Hkkx 6%** bl iz\'u dk mÙkj nsa ;fn vki ,slk pkgasaA                 |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **mfpr ckWDl ij fu\'kku yxk,a vkSj \[your school, homeless liaison,   |
| migrant coordinator\] ls laidZ djsaA**                                |
|                                                                       |
| **vU; lHkh dqVqfEc;ksa ds fy, funsZ\'kksa dk ikyudj vkosnu QkWeZ      |
| HkjsaA**                                                              |
+-----------------------------------------------------------------------+

+----------------------------------------------------------------------+
| **;fn vki ikfyr cPps ds fy, vkosnu dj jgs gSa\] bu funsZ\'kksa dk    |
| ikyu djsa%**                                                         |
|                                                                      |
| **Hkkx 1% izR;sd ikfyr cPps ds fy, vyx vkosnu QkWeZ iz;ksx djsaA**   |
| cPps dk uke\] Ldwy vkSj xzsM fy\[ksaA                                |
|                                                                      |
| **Hkkx 2%** ;g Hkkx NksM+ nsa                                        |
|                                                                      |
| **Hkkx 3%** ckWDl ij fu\'kku yxk, vkSj cPps dh O;fDrxr iz;ksx dh     |
| ekfld vk;\] ;fn dksbZ gks\] fy\[ksaA                                 |
|                                                                      |
| **Hkkx 4%** ;g Hkkx NksM nsaA                                        |
|                                                                      |
| **Hkkx 5%** QkWeZ ij gLrk{kj djsaA lkekftd lqj{kk la\[;k t:jh ughaa  |
| gSA                                                                  |
|                                                                      |
| **Hkkx 6%** bl iz\'u dk mÙkj nsa ;fn vki ,slk pkgsaA                 |
+----------------------------------------------------------------------+
| **MCY;wvkbZlh dqVqfEc;ksa lfgr ?kj ds vU; lHkh yksx\] bu funsZ\'kksa |
| dk ikyu djsa%**                                                      |
|                                                                      |
| **Hkkx 1%** izR;sd cPps dk uke\] Ldwy vkSj xzsM fy\[ksaA             |
|                                                                      |
| **Hkkx 2%** mfpr ckWDl ij fu\'kku yxk,a\] ;fn dksbZ gksA             |
|                                                                      |
| **Hkkx 3%** ;g Hkkx NksM+ nsaA                                       |
|                                                                      |
| **Hkkx 4%** fiNys ekg ls dqy ?kjsyw vk; dh lwpuk ds fy, bu           |
| funsZ\'kksa dk ikyu djsaA                                            |
|                                                                      |
| > **dkWye 1&uke%** vkidks vius ?kj esa jgus okys\] laca/kh gks ;k    |
| > ugha\] **izR;sd** O;fDr dk izFke vkSj vafre uke fy\[ksa ¼tSls      |
| > nknk&nknh\] vU; laca/kh ;k fe=½A vkidks Lo;a dks vkSj vius lkFk    |
| > jgus okys lHkh cPpksa dks \'kkfey djuk t:jh gSA ;fn vkidks t:jr    |
| > gks\] vU; dkxt \'khV layXu djsaA                                   |
| >                                                                    |
| > **dkWye 2&fiNys ekg dh ldy vk; vkSj ;g fdruh ckj izkIr gqbZ FkhA** |
| > izR;sd O;fDr ds uke ds ckn fiNys ekg izkIr gqbZ vk; dk izR;sd      |
| > izdkj vkSj ;g fdruh ckj izkIr gqbZ\] fy\[ksaA mnkgj.k ds fy,\]     |
| > *dk;Z ls çkfIr;ka%* izR;sd O;fDr dh dk;Z ls vftZr **ldy vk;**      |
| > fy\[ksaaA ;g ?kj esa osru tSlk ugha gSA **ldy vk; djksa vkSj vU;   |
| > dVkSfr;ksa ls iwoZ vftZr jkf\'k gSA** ;g jkf\'k vkidh osru iphZ ij |
| > fy\[kh gksuh pkfg, vFkok vkidk ckWl vkidks crk ldrk gSA [jkf\'k ds |
| > ckn\] fy\[ksa fd bl O;fDr us ;g fdruh ckj izkIr dh ¼g¶rs esa\]     |
| > izR;sd nwljs g¶rs esa\] ekg esa nks ckj ;k ekg esa ,d              |
| > ckj½A]{.underline} *vU; leLr vk;%* og jkf\'k fy\[ksa tks izR;sd    |
| > O;fDr us dY;k.k\] cky lgk;rk\] HkÙkk\] ¼nwljk dkWye½ isa\'ku\]     |
| > lsokfuo\`fÙk\] lkekftd lqj{kk ¼rhljk dkWye½ vkSj vU; lHkh vk;      |
| > lzksrksa ¼pkSFkk dkWye½ ls fiNys ekg izkIr dh FkhA vU; lHkh        |
| > dkWyeksa esa\] ftlesa deZpkjh dks NwV\] csjkstxkjh\] gM+rky ykHk\] |
| > iwjd lqj{kk vk;¼,l,lvkbZ½\] vuqHko ykHk ¼oh, ykHk½\] v{kerk ykHk\] |
| > mu yksxksa ls fu;fer ;ksxnku tks vkids ?kj esa ugha jgrs ;k vU;    |
| > dksbZ vk; \'kkfey gSA Lo%LokfeRo O;olk;\] QkeZ ;k fdjk;s dh vk; ds |
| > fy, \'kq} vk; dh lwpuk nsaA [jkf\'k ds ckn\] fy\[ksa fd bl O;fDr   |
| > us ;g fdruh ckj izkIr dhA]{.underline} ;fn vki fefyVjh vkokl       |
| > futhdj.k igy esa gSa\] ;g vkokl HkÙkk \'kkfey u djsaA              |
| >                                                                    |
| > **dkWye 3&;fn dksbZ vk; u gks\] fu\'kku yxk,a%** ;fn O;fDr dh      |
| > dksbZ vk; u gks\] bl ckWDl ij fu\'kku yxk,aA                       |
|                                                                      |
| **Hkkx 5%** ?kj ds fdlh o;Ld lnL; dks QkWeZ ij gLrk{kj djuk vkSj     |
| viuh lkekftd lqj{kk la\[;k fy\[kuk ;k ckWDl ij fu\'kku yxkuk\] ;fn   |
| mlds ikl u gks\] t:jh gSA                                            |
|                                                                      |
| **Hkkx 6%** bl iz\'u dk mÙkj nsa ;fn vki pkgsaA                      |
+----------------------------------------------------------------------+

**eq¶r vkSj ?kVs ewY; ij Ldwyh Hkkstu ifjokj dk vkosnu QkWeZ**

+---------------+---+----------+-----+----+---+----------+--------+-----+
| **Hkkx 1-     |   |          |     |    |   |          |        |     |
| Ldwy esa cPps |   |          |     |    |   |          |        |     |
| ¼izR;sd ikfyr |   |          |     |    |   |          |        |     |
| cPps ds fy,   |   |          |     |    |   |          |        |     |
| vyx vkosnu    |   |          |     |    |   |          |        |     |
| QkWeZ iz;ksx  |   |          |     |    |   |          |        |     |
| djsa½**       |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| Ldwy esa lHkh |   | Ldwy dk  |     | xz |   | QwM      |        |     |
| cPpksa ds uke |   | uke      |     | sM |   | LVSai ;k |        |     |
|               |   |          |     |    |   | Vh,,u,Q  |        |     |
| ¼izFke\]      |   |          |     |    |   | dsl \#   |        |     |
| e/;\] vafre½  |   |          |     |    |   | ¼;fn     |        |     |
|               |   |          |     |    |   | dksbZ    |        |     |
|               |   |          |     |    |   | gks½A    |        |     |
|               |   |          |     |    |   | H**kkx 5 |        |     |
|               |   |          |     |    |   | NksM+sa  |        |     |
|               |   |          |     |    |   | ;fn      |        |     |
|               |   |          |     |    |   | vkius    |        |     |
|               |   |          |     |    |   | QwM      |        |     |
|               |   |          |     |    |   | LVSai ;k |        |     |
|               |   |          |     |    |   | Vh,,u,Q  |        |     |
|               |   |          |     |    |   | dsl** \# |        |     |
|               |   |          |     |    |   | **fy\[kk |        |     |
|               |   |          |     |    |   | gS**     |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **Hkkx 2- ;fn |   |          |     |    |   |          |        |     |
| cPpk vki      |   |          |     |    |   |          |        |     |
| ftlds fy,     |   |          |     |    |   |          |        |     |
| vkosnu dj jgs |   |          |     |    |   |          |        |     |
| gSa\] cs?kj\] |   |          |     |    |   |          |        |     |
| vkizoklh ;k   |   |          |     |    |   |          |        |     |
| Hkkxk gqvk gS |   |          |     |    |   |          |        |     |
| rks mfpr      |   |          |     |    |   |          |        |     |
| ckWDl ij      |   |          |     |    |   |          |        |     |
| fu\'kku yxk,a |   |          |     |    |   |          |        |     |
| vkSj**        |   |          |     |    |   |          |        |     |
| **\[your      |   |          |     |    |   |          |        |     |
| school,       |   |          |     |    |   |          |        |     |
| homeless      |   |          |     |    |   |          |        |     |
| liaison,      |   |          |     |    |   |          |        |     |
| migrant       |   |          |     |    |   |          |        |     |
| coordinator   |   |          |     |    |   |          |        |     |
| at phone      |   |          |     |    |   |          |        |     |
| #\]** **dks   |   |          |     |    |   |          |        |     |
| dkWy djsaA**  |   |          |     |    |   |          |        |     |
| cs?kj         |   |          |     |    |   |          |        |     |
| vkizoklh      |   |          |     |    |   |          |        |     |
| Hkkxk gqvk    |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **Hkkx 3-     |   |          |     |    |   |          |        |     |
| ikfyr cPpk**  |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| ;fn ;g vkosnu |   |          |     |    |   |          |        |     |
| ,sls cPps ds  |   |          |     |    |   |          |        |     |
| fy, gS tks    |   |          |     |    |   |          |        |     |
| dY;k.k ,tsalh |   |          |     |    |   |          |        |     |
| ;k dksVZ dh   |   |          |     |    |   |          |        |     |
| dkuwuh        |   |          |     |    |   |          |        |     |
| ftEesnkjh     |   |          |     |    |   |          |        |     |
| gS\] bl ckWDl |   |          |     |    |   |          |        |     |
| ij fu\'kku    |   |          |     |    |   |          |        |     |
| yxk,a vkSj    |   |          |     |    |   |          |        |     |
| fQj cPps dh   |   |          |     |    |   |          |        |     |
| O;fDrxr       |   |          |     |    |   |          |        |     |
| iz;ksx dh     |   |          |     |    |   |          |        |     |
| ekfld vk;     |   |          |     |    |   |          |        |     |
| jkf\'k        |   |          |     |    |   |          |        |     |
| fy\[ksa%      |   |          |     |    |   |          |        |     |
| \$\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_Hkkx |   |          |     |    |   |          |        |     |
| 5 NksM+ nsa   |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **?kj ds      |   |          |     |    |   |          |        |     |
| yksxksa dh    |   |          |     |    |   |          |        |     |
| dqy ldy vk;&  |   |          |     |    |   |          |        |     |
| vkidks gesa   |   |          |     |    |   |          |        |     |
| crkuk t:jh gS |   |          |     |    |   |          |        |     |
| fdruh vkSj    |   |          |     |    |   |          |        |     |
| fdruh ckj**   |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **1- uke\     | * |          |     |    |   |          |        | *   |
| **¼?kj ds     | * |          |     |    |   |          |        | *3- |
| **lHkh        | 2 |          |     |    |   |          |        | ;fn |
| yksxk**sa     | - |          |     |    |   |          |        | dk  |
|               | l |          |     |    |   |          |        | sbZ |
| ds uke        | d |          |     |    |   |          |        | vk; |
| fy\[ksa½      | y |          |     |    |   |          |        | ugh |
|               | v |          |     |    |   |          |        | a\] |
|               | k |          |     |    |   |          |        | f   |
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|               | v |          |     |    |   |          |        | kku |
|               | k |          |     |    |   |          |        | y   |
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|               | j |          |     |    |   |          |        | a** |
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|               | j |          |     |    |   |          |        |     |
|               | s |          |     |    |   |          |        |     |
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|               | k |          |     |    |   |          |        |     |
|               | g |          |     |    |   |          |        |     |
|               | * |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | d |          | dY  |    | i |          | vU;    |     |
|               | V |          | ;k. |    | s |          | lHkh   |     |
|               | k |          | k\] |    | a |          | vk;    |     |
|               | S |          | cky |    | \ |          |        |     |
|               | r |          | lg  |    | ' |          |        |     |
|               | h |          | k;r |    | k |          |        |     |
|               | l |          | k\] |    | u |          |        |     |
|               | s |          | Hk  |    | \ |          |        |     |
|               | i |          | Ùkk |    | ] |          |        |     |
|               | w |          |     |    | l |          |        |     |
|               | o |          |     |    | s |          |        |     |
|               | Z |          |     |    | o |          |        |     |
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|               | k |          |     |    | f |          |        |     |
|               | ; |          |     |    | u |          |        |     |
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|               | l |          |     |    | \ |          |        |     |
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|               | k |          |     |    | Ù |          |        |     |
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|               | a |          |     |    | e |          |        |     |
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|               |   |          |     |    | t |          |        |     |
|               |   |          |     |    | d |          |        |     |
|               |   |          |     |    | l |          |        |     |
|               |   |          |     |    | q |          |        |     |
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|               |   |          |     |    | { |          |        |     |
|               |   |          |     |    | k |          |        |     |
|               |   |          |     |    | k |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| *¼mnkgj.k½*   | * |          | \   |    | \ |          | \$\    | -   |
|               | [ |          | $[1 |    | $ |          | _\_\_\ |     |
| ***tsu        | \ |          | 50/ |    | [ |          | _\_\_/ |     |
| fLeFk***      | $ |          | *** |    | 1 |          | \_\_\_ |     |
|               | 2 |          | lIr |    | 0 |          | \_\_\_ |     |
|               | 0 |          | kg* |    | 0 |          |        |     |
|               | 0 |          | **] |    | / |          |        |     |
|               | / |          | {.u |    | * |          |        |     |
|               | * |          | nde |    | * |          |        |     |
|               | * |          | rli |    | * |          |        |     |
|               | l |          | ne} |    | e |          |        |     |
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|               | } |          |     |    |   |          |        |     |
|               | * |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | \ |          | \   |    | \ |          | \$\    | -   |
|               | $ |          | $\_ |    | $ |          | _\_\_\ |     |
|               | \ |          | \_\ |    | \ |          | _\_\_/ |     |
|               | _ |          | _\_ |    | _ |          | \_\_\_ |     |
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+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | \ |          | \   |    | \ |          | \$\    | -   |
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+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | \ |          | \   |    | \ |          | \$\    | -   |
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+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | \ |          | \   |    | \ |          | \$\    | -   |
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+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | \ |          | \   |    | \ |          | \$\    | -   |
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+---------------+---+----------+-----+----+---+----------+--------+-----+
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+---------------+---+----------+-----+----+---+----------+--------+-----+
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|               | $ |          | $\_ |    | $ |          | _\_\_\ |     |
|               | \ |          | \_\ |    | \ |          | _\_\_/ |     |
|               | _ |          | _\_ |    | _ |          | \_\_\_ |     |
|               | \ |          | \_\ |    | \ |          | \_\_\_ |     |
|               | _ |          | _/\ |    | _ |          |        |     |
|               | \ |          | _\_ |    | \ |          |        |     |
|               | _ |          | \_\ |    | _ |          |        |     |
|               | \ |          | _\_ |    | \ |          |        |     |
|               | _ |          | \_\ |    | _ |          |        |     |
|               | \ |          | _\_ |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | / |          |     |    | / |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
|               | \ |          | \   |    | \ |          | \$\    | -   |
|               | $ |          | $\_ |    | $ |          | _\_\_\ |     |
|               | \ |          | \_\ |    | \ |          | _\_\_/ |     |
|               | _ |          | _\_ |    | _ |          | \_\_\_ |     |
|               | \ |          | \_\ |    | \ |          | \_\_\_ |     |
|               | _ |          | _/\ |    | _ |          |        |     |
|               | \ |          | _\_ |    | \ |          |        |     |
|               | _ |          | \_\ |    | _ |          |        |     |
|               | \ |          | _\_ |    | \ |          |        |     |
|               | _ |          | \_\ |    | _ |          |        |     |
|               | \ |          | _\_ |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | / |          |     |    | / |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
|               | \ |          |     |    | \ |          |        |     |
|               | _ |          |     |    | _ |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **Hkkx 5-     |   |          |     |    |   |          |        |     |
| gLrk{kj vkSj  |   |          |     |    |   |          |        |     |
| lkekftd       |   |          |     |    |   |          |        |     |
| lqj{kk la\[;k |   |          |     |    |   |          |        |     |
| ¼o;Ld ds      |   |          |     |    |   |          |        |     |
| gLrk{kj       |   |          |     |    |   |          |        |     |
| t:jh½**       |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| vkosnu QkWeZ  |   |          |     |    |   |          |        |     |
| ij ?kj ds     |   |          |     |    |   |          |        |     |
| o;Ld lnL; ds  |   |          |     |    |   |          |        |     |
| gLrk{kj t:jh  |   |          |     |    |   |          |        |     |
| gSaA ;fn Hkkx |   |          |     |    |   |          |        |     |
| 4 iw.kZ gS\]  |   |          |     |    |   |          |        |     |
| QkWeZ ij      |   |          |     |    |   |          |        |     |
| gLrk{kj ds    |   |          |     |    |   |          |        |     |
| lkFk o;Ld dks |   |          |     |    |   |          |        |     |
| viuh lkekftd  |   |          |     |    |   |          |        |     |
| lqj{kk la\[;k |   |          |     |    |   |          |        |     |
| fy\[kuk ;k    |   |          |     |    |   |          |        |     |
| \^\^esjs ikl  |   |          |     |    |   |          |        |     |
| lkekftd       |   |          |     |    |   |          |        |     |
| lqj{kk la\[;k |   |          |     |    |   |          |        |     |
| ugha gS\*\*   |   |          |     |    |   |          |        |     |
| ckWDl ij      |   |          |     |    |   |          |        |     |
| fu\'kku yxkuk |   |          |     |    |   |          |        |     |
| t:jh gSA ¼bl  |   |          |     |    |   |          |        |     |
| ist ds fiNyh  |   |          |     |    |   |          |        |     |
| rjQ xksiuh;rk |   |          |     |    |   |          |        |     |
| vf/kfu;e      |   |          |     |    |   |          |        |     |
| fooj.k        |   |          |     |    |   |          |        |     |
| ns\[ksaA½     |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| *eSa izekf.kr |   |          |     |    |   |          |        |     |
| djrk ¼opu     |   |          |     |    |   |          |        |     |
| nsrk½ gwa fd  |   |          |     |    |   |          |        |     |
| bl vkosnu     |   |          |     |    |   |          |        |     |
| QkWeZ esa nh  |   |          |     |    |   |          |        |     |
| xbZ lHkh      |   |          |     |    |   |          |        |     |
| lwpuk,a lR;   |   |          |     |    |   |          |        |     |
| gSa vkSj leLr |   |          |     |    |   |          |        |     |
| vk; dh lwpuk  |   |          |     |    |   |          |        |     |
| nh xbZ gSA    |   |          |     |    |   |          |        |     |
| eSa le\>rk    |   |          |     |    |   |          |        |     |
| gwa fd Ldwy   |   |          |     |    |   |          |        |     |
| esjs }kjk nh  |   |          |     |    |   |          |        |     |
| xbZ lwpuk ds  |   |          |     |    |   |          |        |     |
| vk/kkj ij     |   |          |     |    |   |          |        |     |
| la?kh; fuf/k  |   |          |     |    |   |          |        |     |
| izkIr djsxkA  |   |          |     |    |   |          |        |     |
| eSa le\>rk    |   |          |     |    |   |          |        |     |
| gwa fd Ldwy   |   |          |     |    |   |          |        |     |
| vf/kdkjh      |   |          |     |    |   |          |        |     |
| lwpukvksa dk  |   |          |     |    |   |          |        |     |
| lR;kiu ¼tkap½ |   |          |     |    |   |          |        |     |
| dj ldrs gSaA  |   |          |     |    |   |          |        |     |
| eSa le\>rk    |   |          |     |    |   |          |        |     |
| gwa fd ;fn    |   |          |     |    |   |          |        |     |
| eSa bjknru    |   |          |     |    |   |          |        |     |
| \>wBh lwpuk   |   |          |     |    |   |          |        |     |
| nsrk gwa\]    |   |          |     |    |   |          |        |     |
| esjs cPps     |   |          |     |    |   |          |        |     |
| Hkkstu ykHk   |   |          |     |    |   |          |        |     |
| \[kks ldrs    |   |          |     |    |   |          |        |     |
| gSa vkSj eq\> |   |          |     |    |   |          |        |     |
| ij eqdnek     |   |          |     |    |   |          |        |     |
| pyk;k tk ldrk |   |          |     |    |   |          |        |     |
| gSA*          |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| ;gka gLrk{kj  |   |          |     |    |   |          |        |     |
| djsa%         |   |          |     |    |   |          |        |     |
| X\_\          |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_fizaV |   |          |     |    |   |          |        |     |
| uke:\_        |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| rkjh\[k:      |   |          |     |    |   |          |        |     |
| \_            |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| irk:\_\_\_    |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Qksu          |   |          |     |    |   |          |        |     |
| uacj:         |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| lkekftd       |   |          |     |    |   |          |        |     |
| lqj{kk        |   |          |     |    |   |          |        |     |
| la\[;k: \_\_  |   |          |     |    |   |          |        |     |
| \_\_ \_\_ -   |   |          |     |    |   |          |        |     |
| \_\_ \_\_ -   |   |          |     |    |   |          |        |     |
| \_\_ \_\_     |   |          |     |    |   |          |        |     |
| \_\_ \_\_     |   |          |     |    |   |          |        |     |
| esjs ikl      |   |          |     |    |   |          |        |     |
| lkekftd       |   |          |     |    |   |          |        |     |
| lqj{kk la\[;k |   |          |     |    |   |          |        |     |
| ugha gS       |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **Hkkx 6-     |   |          |     |    |   |          |        |     |
| cPpksa dh     |   |          |     |    |   |          |        |     |
| uLyh vkSj     |   |          |     |    |   |          |        |     |
| tkrh; igpku   |   |          |     |    |   |          |        |     |
| ¼oSdfYid½**   |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| [,d ;k vf/kd  |   |          |     |    |   |          |        |     |
| uLyh igpkuksa |   |          |     |    |   |          |        |     |
| ij fu\'kku    |   |          |     |    |   |          |        |     |
| yxk,a:        |   |          |     |    |   |          |        |     |
| ]{.underline} |   |          |     |    |   |          |        |     |
| [,d tkrh;     |   |          |     |    |   |          |        |     |
| igpku ij      |   |          |     |    |   |          |        |     |
| fu\'kku       |   |          |     |    |   |          |        |     |
| yxk,a:        |   |          |     |    |   |          |        |     |
| ]{.underline} |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| -   ,f\'k;kbZ |   |          |     |    |   |          |        |     |
|     vesfjdh   |   |          |     |    |   |          |        |     |
|     Hkkjrh;   |   |          |     |    |   |          |        |     |
|     ;k ewy    |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
|    vykLdkoklh |   |          |     |    |   |          |        |     |
|     fgLisuh   |   |          |     |    |   |          |        |     |
|     ;k ykfruh |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| -   xksjk ewy |   |          |     |    |   |          |        |     |
|     gokbZ ;k  |   |          |     |    |   |          |        |     |
|     vU;       |   |          |     |    |   |          |        |     |
|     iSlhfQd   |   |          |     |    |   |          |        |     |
|     }hioklh   |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
|   xSj&fgLisuh |   |          |     |    |   |          |        |     |
|     ;k        |   |          |     |    |   |          |        |     |
|     ykfruhs   |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| dkyk ;k vÝhdh |   |          |     |    |   |          |        |     |
| vesfjdh vU;   |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| **;g Hkkx u   |   |          |     |    |   |          |        |     |
| HkjsaA ;g     |   |          |     |    |   |          |        |     |
| dsoy Ldwy     |   |          |     |    |   |          |        |     |
| iz;ksx ds fy, |   |          |     |    |   |          |        |     |
| gSA**         |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+
| Annual Income |   |          |     |    |   |          |        |     |
| Conversion:   |   |          |     |    |   |          |        |     |
| Weekly x 52,  |   |          |     |    |   |          |        |     |
| Every 2 Weeks |   |          |     |    |   |          |        |     |
| x 26, Twice A |   |          |     |    |   |          |        |     |
| Month x 24    |   |          |     |    |   |          |        |     |
| Monthly x 12  |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| Total Income: |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\   |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Per: Week,    |   |          |     |    |   |          |        |     |
| Every 2       |   |          |     |    |   |          |        |     |
| Weeks, Twice  |   |          |     |    |   |          |        |     |
| A Month,      |   |          |     |    |   |          |        |     |
| Month, Year   |   |          |     |    |   |          |        |     |
| Household     |   |          |     |    |   |          |        |     |
| size:         |   |          |     |    |   |          |        |     |
| \_\           |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| Categorical   |   |          |     |    |   |          |        |     |
| Eligibility:  |   |          |     |    |   |          |        |     |
| \_\_\_ Date   |   |          |     |    |   |          |        |     |
| Withdrawn:    |   |          |     |    |   |          |        |     |
| \_            |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _Eligibility: |   |          |     |    |   |          |        |     |
| Free\_\_\_    |   |          |     |    |   |          |        |     |
| Reduced\_\_\_ |   |          |     |    |   |          |        |     |
| Denied\_\_\_  |   |          |     |    |   |          |        |     |
| Reason:       |   |          |     |    |   |          |        |     |
| \_\_\_\       |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| Temporary:    |   |          |     |    |   |          |        |     |
| F             |   |          |     |    |   |          |        |     |
| ree\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Redu          |   |          |     |    |   |          |        |     |
| ced\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Time Period:  |   |          |     |    |   |          |        |     |
| \_\_\_\_\     |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| (expires      |   |          |     |    |   |          |        |     |
| after         |   |          |     |    |   |          |        |     |
| \_\_\_\_\_    |   |          |     |    |   |          |        |     |
| days)         |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| Determining   |   |          |     |    |   |          |        |     |
| Official's    |   |          |     |    |   |          |        |     |
| Signature:    |   |          |     |    |   |          |        |     |
| \_\_\         |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Date:         |   |          |     |    |   |          |        |     |
| \_            |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
|               |   |          |     |    |   |          |        |     |
| Confirming    |   |          |     |    |   |          |        |     |
| Official's    |   |          |     |    |   |          |        |     |
| Signature:    |   |          |     |    |   |          |        |     |
| \_\_\_\_      |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Date:         |   |          |     |    |   |          |        |     |
| \             |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Follow-up     |   |          |     |    |   |          |        |     |
| Official's    |   |          |     |    |   |          |        |     |
| Signature:    |   |          |     |    |   |          |        |     |
| \_\_\_\_\_    |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_\ |   |          |     |    |   |          |        |     |
| _\_\_\_\_\_\_ |   |          |     |    |   |          |        |     |
| Date:         |   |          |     |    |   |          |        |     |
| \_\_\_\_\_\_  |   |          |     |    |   |          |        |     |
+---------------+---+----------+-----+----+---+----------+--------+-----+

**;fn vkids dqVqEc dh vk; bl pkVZ ij lhek ds Hkhrj gksrh gS\] vkids cPps
eq¶r ;k ?kVs ewY; ij Hkkstu ds fy, ik=rk izkIr dj ldrs gSaA**

**xksiuh;rk vf/kfu;e fooj.k% ;g crkrk gS fd ge vkids }kjk nh xbZ lwpuk
dSls iz;ksx djsaxsA**

fjpMZ ch- jly us\'kuy Ldwy yap ,DV ds rgr bl vkosnu QkWeZ ij lwpuk nsuk
t:jh gSA vki lwpuk nsus ds fy, ck/; ugha gS\] ysfdu ;fn vki ugha nsrs\]
ge vkids cPps dks eq¶r ;k ?kVs ewY; ij Hkkstu ds fy, Lohdkj ugha dj
ldrsA vkidks dqVqEc ds o;Ld lnL; dh lkekftd lqj{kk la\[;k \'kkfey djuk
t:jh gS ftlus vkosnu QkWeZ ij gLrk{kj fd, gSaA ;fn vki fdlh ikfyr cPps
dh vksj ls vkosnu dj jgs gSa vFkok vki QwM LVSai dk;ZØe\] t:jrean
ifjokjksa ds fy, vLFkkbZ lgk;rk ¼Vh,,u,Q½ dk;ZØe ;k Hkkjrh; vkjf{kr
Hkkstu forj.k dk;ZØe ¼,QMhihvkbZvkj½ ekeyk la\[;k ;k vkids cPps dh vU;
,QMhihvkbZvkj igpku ;k tc vki n\'kkZrs gSa fd bl vkosnu ij gLrk{kj djus
okys dqVqEc ds o;Ld lnL; ds ikl lkekftd lqj{kk la\[;k ugha gS\] lkekftd
lqj{kk la\[;k t:jh ugha gSA ge vkidh lwpuk ;g fu/kkZfjr djus ds fy,
iz;ksx djsaxs fd vkidk cPpk eq¶r ;k ?kVs ewY; ij Hkkstu vkSj yap rFkk
uk\'rk dk;ZØe dh O;oLFkk vkSj tkjh djus ds fy, ik= gSA ge vkidh ik=rk
lwpuk f\'k{kk\] LokLF; vkSj iks\"k.k dk;ZØeksa ds lkFk ckaV ldrs gSa
ftlls mUgsa muds dk;ZØeksa ds vkdyu\] fuf/k ;k ykHk ds fu/kkZj.k\]
dk;ZØe leh{kk ds fuxjkuhdÙkkZ vkSj dk;ZØe fu;eksa ds mYya?ku ij uT+kj
j\[kus ds fy, çorZu vf/kdkfj;ksa dks enn feysxhA

**xSj&HksnHkko fooj.k% ;g crkrk gS fd ;fn vki le\>rs gSa fd vkils vuqfpr
O;ogkj gqvk gS rks D;k djuk pkfg,A** la?kh; dkuwu vkSj vesfjdh Ñf\"k
uhfr foHkkx ds vuqlkj\] bl laLFkku esa tkfr\] jax\] jk\"Vªh; ewy\]
fyax\] vk;q ;k v{kerk ds vk/kkj ij HksnHkko djuk izfrcaf/kr g[S]{.mark}A
HksnHkko dh f\'kdk;r ntZ djus ds fy,\] *;w,lMh,\] funs\'kd\] ukxfjd
vf/kdkj dk;kZy;\] 1400 baMhisaMsal ,osU;w\] ,lMCY;w\] okf\'kaxVu Mhlh
20250&9410* *USDA, Director, Office of Civil Rights, 1400 Independence
Avenue, SW, Washington DC 20250-9410* dks fy\[ksa ;k 800&795&3272 ;k
202&720&6382 ¼VhVhok;½ ij dkWy djsaA ;w,lMh, ,d leku volj iznkrk vkSj
fu;ksDrk gSA

**esfMdsM@,llh,pvkbZih ds lkFk lwpuk ckaVuk**

fiz; vfHkHkkod@laj{kd%

;fn vkids cPps eq¶r ;k ?kVs ewY; ij Ldwy Hkkstu izkIr djrs gSa\] os
esfMdsM ;k jkT; ds cky LokLF; chek dk;ZØe ¼,llh,pvkbZih½ }kjk eq¶r ;k
?kVs ewY; ij LokLF; chek izkIr djus ds ik= Hkh gks ldrs gSaA LokLF; chek
ds lkFk cPpksa dh fu;fer LokLF; ns\[kHkky dh laHkkouk vf/kd gksrh gS
vkSj chekjh ds dkj.k Ldwy ls Nqêh dh laHkkouk de jgrh gSA

pwafd LokLF; chek cPpks dh HkykbZ ds fy, cgqr egRoiw.kZ gS\] **dkuwu
gesa esfMdsM vkSj ,llh,pvkbZih dh tkudkjh nsus dh vuqefr nsrk gS fd
vkids cPps eq¶r ;k ?kVs ewY; ij Hkkstu ds ik= gSa\] *tc rd vki gesa ugha
u dgsa***A esfMdsM vkSj ,llh,pvkbZih dsoy mu cPpksa dh igpku ds fy,
lwpuk iz;ksx djsxk tks muds dk;ZØeksa ds ik= gks ldrs gSaA dk;ZØe
vf/kdkjh vkids cPpksa ds ukekadu ds fy, vki ls laidZ dj ldrs gSa ¼eq¶r
vkSj ?kVs ewY; ij Ldwy Hkkstu vkosnu QkWeZ Hkj nsus ls vkids cPps Lor%
LokLF; chek esa ukekafdr ugha gksrs½A

;fn vki ugha pkgrs fd ge vkidh lwpuk esfMdsM ;k ,llh,pvkbZih ds lkFk
ckaVs\] uhps fn;k QkWeZ Hkjsa vkSj Hkst nsa ¼;g QkWeZ Hkstus ls bl ckr
ij dksbZ izHkko ugha i\<+sxk fd vkids cPps eq¶r ;k ?kVs ewY; ij Hkkstu
izkIr djrs gaS ;k ugha½A

-   **ugha! eSa ugha** pkgrk fd esjs eq¶r vkSj ?kVs ewY; ij Ldwy Hkkstu
    vkosnu QkWeZ ls tkudkjh esfMdsM ;k jkT; ds cky LokLF; chek dk;ZØe ls
    ckaVh tk,A

**;fn vkius ugha ij fu\'kku yxk;k gS\] uhps fn;k QkWeZ HkjsaA**

cPps dk uke% \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Ldwy%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

cPps dk uke% \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ldwy%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

cPps dk uke%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ldwy%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

cPps dk uke%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ldwy%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

vfHkHkkod@laj{kd ds gLrk{kj%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_rkjh\[k%
\_\_\_\_\_\_\_\_\_

eqfnzr uke% \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ irk%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

vf/kd tkudkjh ds fy,\] vki **\[name\]** dks **\[phone\]** ij dkWy dj
ldrs gSaA

**;g QkWeZ okfil Hkstsa% \[date\]** **rd \[address\] ij**

**vU; dk;ZØeksa ds lkFk lwpuk ckaVuk**

fiz; vfHkHkkod@laj{kd%

vkidk le; vkSj iz;kl cpkus ds fy,\] vkids eq¶r vkSj ?kVs ewY; ij Ldwy
Hkkstu vkosnu QkWeZ ij vkids }kjk nh xbZ tkudkjh vU; dk;ZØeksa ds lkFk
ckaVh tk ldrh gSa ftuds fy, vkids cPps ik=rk izkIr dj ldrs gSaA
**fuEufyf\[kr dk;ZØeksa ds fy,\] vkidh lwpuk ckaVus ds fy, gesa vkidh
vuqefr t:jh gSA ;g QkWeZ Hkstus ls bl ckr ij dksbZ izHkko ugha iM+sxk fd
vkidk cPpk eq¶r ;k ?kVs ewY; ij Ldwy Hkkstu izkIr djrk gS ;k ughaA**

-   ugha! **eSa ugha** pkgrk fd esjs eq¶r vkSj ?kVs ewY; ij Ldwy Hkkstu
    vkosnu QkWeZ ls tkudkjh buesa ls fdlh Hkh dk;ZØe ls ckaVh tk,A

-   gka! **eSa** pkgrk gwa fd Ldwy ds vf/kdkjh esjs eq¶r vkSj ?kVs ewY;
    ij Ldwy Hkkstu vkosnu QkWeZ ls tkudkjh **\[name of program specific
    to your school\]** ds lkFk ckaVsA

-   gka! **eSa** pkgrk gwa fd Ldwy ds vf/kdkjh esjs eq¶r vkSj ?kVs ewY;
    ij Ldwy Hkkstu vkosnu QkWeZ ls tkudkjh **\[name of program specific
    to your school\]** ds lkFk ckaVsA

-   gka! **eSa** pkgrk gwa fd Ldwy ds vf/kdkjh esjs eq¶r vkSj ?kVs ewY;
    ij Ldwy Hkkstu vkosnu QkWeZ ls tkudkjh **\[name of program specific
    to your school\]** ds lkFk ckaVsA

**;fn vkius mijksDr fdlh ;k lHkh ckWDl ij gka ij fu\'kku yxk;k gS\] uhps
fn;k QkWeZ HkjsaA vkidh tkudkjh dssoy vkids }kjk pqus dk;ZØeksa ds lkFk
ckaVh tk,xhA**

cPps dk uke% \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Ldwy%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

cPps dk uke% \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ldwy%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

cPps dk uke%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ldwy%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

cPps dk uke%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ldwy%\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

vfHkHkkod@laj{kd ds gLrk{kj%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_rkjh\[k%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

eqfnzr uke:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

irk:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

vf/kd tkudkjh ds fy,\] vki dkWy **\[name\]** dks **\[phone\]** ij dkWy
dj ldrs gSaA

**;g QkWeZ okfil Hkstsa% \[date\]** **rd \[address\] ij**

**gesa vkids vkosnu dh tkap djuk t:jh gS**

**vkidks gekjh t:jr dh lwpuk Hkstuk ;k** **\[date\]** **rd**
**\[name\]** **ls laidZ djuk t:jh gS\] vU;Fkk vkids cPpksa dks eq¶r ;k
?kVs ewY; ij Hkkstu feyuk can gks tk,xkA**

Ldwy%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
rkjh\[k% \_\_\_\_\_\_\_\_\_\_\_\_

fiz;
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:

ge vkids eq¶r vkSj ?kVs ewY; ij Ldwy Hkkstu ds vkosnu QkWeZ dh tkap dj
jgs gSaA la?kh; fu;eksa esa okafNr\] ge ;g lqfuf\'pr djus fd dsoy ;ksX;
cPps eq¶r ;k ?kVs ewY; ij Hkkstu izkIr djsa\] ;g djrs gSaA vkidks
çekf.kr djus fd **\[names of children\]** ik= gSa\] gesa lwpuk Hkstuk
t:jh gSA

;fn laHko gks\] izfr;ka Hkstsa ewy nLrkost ugha\] ;fn vki ewy nLrkost
Hkstrs gSa\] os vkidks dsoy rHkh okil Hksts tk,aaxs tc vki dgsaxsA

**1- ;fn vki eq¶r ;k ?kVs ewY; ij Hkkstu ds fy, vkonsu djus ;k rc ls
fdlh le; QwM LVSai ;k Vh,,u,Q izkIr dj jgs Fks\] buesa ls fdlh dh dkWih
gesa Hkstsa%**

-   QwM LVSai ;k Vh,,u,Q Áek.khdj.k uksfVl ftlij Áek.khdj.k dh rkjh\[k
    çnf\'kZr gksA

-   QwM LVSai ;k dY;k.k dk;kZy; ls i= ftlls Li\"V gks fd vkidks QwM
    LVSai ;k Vh,,u,Q izkIr gqvk gSA

-   **viuk bZchVh dkMZ u HkstsaA**

**2- ;fn vki ;g i= cs?kj\] izoklh ;k Hkkxs gq, cPps ds fy, izkIr djrs
gSa\] ---i;k lgk;rk ds fy, \[school, homeless liaison, or migrant
coordinator\] ls laidZ djsaA**

**3-** **;fn ;g cPpk ikfyr cPpk gS%**

gesa cPps dh izk;kstd ,tsalh ls vf/kdkfjd nLrkost HkstsaA

**4- ;fn vki vius cPps ds fy, QwM LVSai ;k Vh,,u,Q izkIr ugh djrs gSa%**

d- uhps dqVqEc ds izR;sd o;Ld lnL; dk uke vkSj lkekftd lqj{kk la\[;k
fy\[ksaA

+----------------------------+--------------------------------+--------+
| uke                        | > lkekftd lqj{kk la\[;k        | dksbZ  |
|                            | >                              | lkek-  |
|                            | > ¼xksiuh;rk vf/kfu;e fooj.k\] | lqj{kk |
|                            | > ist 2 ns\[ksa½               | la     |
|                            |                                | -ughaa |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+
| \_\_\_\_\_\_\_\_\_\_\_     | \_\_ \_\_ \_\_ - \_\_ \_\_ -   | -      |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_ \_\_ \_\_ \_\_            |        |
+----------------------------+--------------------------------+--------+

\[k- ;g ist mu nLrkostksa ds lkFk Hkstsa tks vkids dqVqEc ds vk; ds
izR;sd lzksr ls /kujkf\'k n\'kkZrs gksaA

Hksts tkus okys nLrkost esa ml O;fDr dk **uke** tks vk; izkIr djrk gS\]
**rkjh\[k** ftlesas feyh\] **fdruh** feyh vkSj **fdruh ckj** feyh\]
iznf\'kZr gksuk t:jh gSA **lwpuk Hkstsa%** **\[address\]**

**[Lohdk;Z nLrkostksa esa \'kkfey gSa%]{.underline}**

**ukSdjh%** osruiphZ ;k osru fyQkQk ftl ij jkf\'k vkSj fdruh ckj osru
feyk\] vafdr gks( ldy HkÙks vkSj fdruh ckj Hkqxrku gqvk n\'kkZrk
fu;ksDrk dk i=( vFkok O;olk; ;k \[ksrh ds nLrkost tSls \[kkrs ;k VSDl
cqDlA

**lkekftd lqj{kk\] isa\'ku ;k lsokfuo\`fÙk%** lkekftd lqj{kk
lsokfuo\`fÙk ykHk i=\] izkIr ykHkksa dk fooj.k ;k isa\'ku iznku fd, tkus
dh lwpukA

**csjkstxkj\] v{kerk ;k deZpkjh HkÙkk%** jkT; jkstxkj lqj{kk dk;kZy; ls
ik=rk dh lwpuk\] osru iphZ ;k deZpkjh HkÙks dk i=A

**dY;k.k Hkqxrku%** dY;k.k ,taslh ls ykHk dk i=A

**cky lgk;rk vFkok \[kpkZ HkÙkk%** vnkyrh QSlyk\] vuqca/k ;k izkIr
pSdksa dh dkWfi;kaA

**vU; vk; ¼tSls fdjk, dh vk;½%** lwpuk ftlls izkIr vk;\] fdruh ckj vk;
vkSj izfIr rkjh\[k iznf\'kZr gksA

**dksbZ vk; ugha%** ;g O;k\[;k djrs gq, fd vkids dqVqEc dks Hkkstu\]
diM+s vkSj vkokl dSls miyC/k gksrk gS vkSj vkidks dc vk; dh vk\'kk gS\]
laf{kIr ys\[kA

**fefyVjh vkokl futhdj.k igy%** i= ;k fdjk;k vuqca/k tks n\'kkZrk gks fd
vkidk vkokl fefyVjh vkokl futhdj.k igy dk fgLlk gSA

**Lohdk;Z vk; nLrkosthdj.k dh le;lhek%** Ñi;k os nLrkost tek djsa tks
ykHkksa ds fy, vkids vkosnu ds le; vkidh vk; n\'kkZrs gksaA ;fn vkids
ikl ;g tkudkjh ugha gS\] vkosnu ds le; ls lR;kiu ds le; rd nLrkost tek
dj ldrs gSaA

;fn vkidk dksbZ iz\'u ;k enn dh t:jr gks\] **\[name\]** ls **\[phone
number\]** ij dkWy djsaA ;g dkWy eq¶r gSA **\[Toll free or reverse
charge explanation\]**

Hkonh;\]

**\[signature\]**

xksiuh;rk vf/kfu;e fooj.k% fjpMZ ch- jly us\'kuy Ldwy yap ,DV ds rgr bl
vkosnu QkWeZ ij lwpuk nsuk t:jh gSA vki lwpuk nsus ds fy, ck/; ugha gS\]
ysfdu ;fn vki ugha nsrs\] ge vkids cPps dks eq¶r ;k ?kVs ewY; ij Hkkstu
ds fy, Lohdkj ugha dj ldrsA vkidks dqVqEc ds o;Ld lnL; dh lkekftd lqj{kk
la\[;k \'kkfey djuk t:jh gSA ;fn vki fdlh ikfyr cPps dh vksj ls vkosnu
dj jgs gSa vFkok vki QwM LVSai dk;ZØe\] t:jrean ifjokjksa ds fy, vLFkkbZ
lgk;rk ¼Vh,,u,Q½ dk;ZØe ;k Hkkjrh; vkjf{kr Hkkstu forj.k dk;ZØe
¼,QMhihvkbZvkj½ ekeyk la\[;k ;k vkids cPps dh vU; ,QMhihvkbZvkj igpku ;k
tc vki n\'kkZrs gSa fd bl vkosnu ij gLrk{kj djus okys dqVqEc ds o;Ld
lnL; ds ikl lkekftd lqj{kk la\[;k ugha gS\] lkekftd lqj{kk la\[;k t:jh
ugha gSA ge vkidh lwpuk ;g fu/kkZfjr djus ds fy, iz;ksx djsaxs fd vkidk
cPpk eq¶r ;k ?kVs ewY; ij Hkkstu vkSj yap rFkk uk\'rk dk;ZØe dh O;oLFkk
vkSj tkjh djus ds fy, ik= gSA

xSj&HksnHkko fooj.k% ;g crkrk gS fd ;fn vki le\>rs gSa fd vkils vuqfpr
O;ogkj gqvk gS rks D;k djuk pkfg,A la?kh; dkuwu vkSj vesfjdh Ñf\"k uhfr
foHkkx ds vuqlkj\] bl laLFkku esa tkfr\] jax\] jk\"Vªh; ewy\] fyax\]
vk;q ;k v{kerk ds vk/kkj ij HksnHkko djuk izfrcaf/kr gSA HksnHkko dh
f\'kdk;r ntZ djus ds fy,\] *;w,lMh,\] funs\'kd\] ukxfjd vf/kdkj
dk;kZy;\] 1400 baMhisaMsal ,osU;w\] ,lMCY;w\] okf\'kaxVu Mhlh 20250&9410
USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW,
Washington DC 20250-9410* dks fy\[ksa ;k 800&795&3272 ;k 202&720&6382
¼VhVhok;½ ij dkWy djsaA ;w,lMh, ,d leku volj iznkrk vkSj fu;ksDrk gSA

**geus vkids vkosnu dh tkap dh gS**

Ldwy%
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
rkjh\[k% \_\_\_\_\_\_\_\_\_\_\_\_

fiz; \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_:

geus ml lwpuk dh tkap dh gS ftls vkius çekf.kr djus fd **\[names of
children\]** eq¶r vkSj ?kVs ewY; ij Hkkstu dk ik= gS vkSj fu.kZ; fy;k gS
fd%

-   vkids cPps dh ik=rk cnyh ugha gSA

-   **\[date\]** ls vkids cPps dh Hkkstu dh ik=rk dks **?kVs ewY; ls
    eq¶r** esa cny fn;k tk,xk D;ksafd vkidh vk; eq¶r Hkkstu ik=rk lhek
    ds Hkhrj gSA vkids cPps dks fu%\'kqYd Hkkstu feysxkA

-   **\[date\]** ls vkids cPps dh Hkkstu dh ik=rk dks **eq¶r ls ?kVs
    ewY;** esa cny fn;k tk,xk D;ksafd vkidh vk; eq¶r Hkkstu ik=rk lhek
    ls vf/kd gSA ?kVh nj ij Hkkstu dk ewY; **\[\$\]** yap ds fy,
    **\[\$\]** vkSj uk\'rs ds fy, **\[\$\]**A

-   **\[date\]** ls **vkids cPps** fuEufyf\[kr dkj.kksa ls eq¶r ;k ?kVs
    ewY; ij Hkkstu **ds ik= ugha** gSa%

> \_\_\_ fjdkWMZ n\'kkZrs gSa fd vkidks QwM LVSai ;k Vh,u,Q ugha feyk
> gSA
>
> \_\_\_ fjdkWMZ n\'kkZrs gSa fd cPps cs?kj\] Hkkxs gq, ;k vizoklh ugha
> gSaA
>
> \_\_\_ vkidh vk; eq¶r ;k ?kVs ewY; ij Hkkstu ik=rk lhek ls vf/kd gSA
>
> \_\_\_ vkius miyC/k ugha djk;k%
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_ vkius gekjs vuqjks/k dk izR;qÙkj ugha fn;kA
>
> yap ds fy, Hkkstu dk ewY; **\[\$\]** vkSj uk\'rs ds fy, **\[\$\]**A
> ;fn vkids dqVqEc dh vk; de gksrh gS ;k vkids dqVqEc dk vkdkj c\<+ tkrk
> gS\] vki fQj ls vkosnu dj ldrs gSaA ;fn vkius ekStqnk ik=rk dk izek.k
> miyC/k ugha djk;k gS\] vkils ,slk djus ds fy, dgk tk,xk ;fn vki
> iqu%vkosnu djrs gSaA

;fn vki bl fu.kZ; vlger gSa vki **\[phone\]** ij **\[name\]** ls ppkZ dj
ldrs gSaA vkidks fu\"i{k lquokbZ dk Hkh vf/kdkj gSA ;fn vki **\[date\]**
rd lquokbZ ds fy, vuqjks/k djrs gSa\] vkids cPpksa dks lquokbZ ds
vf/kdkfjd fu.kZ; gksus rd eq¶r ;k ?kVs ewY; ij Hkkstu feyuk tkjh jgsxkA
vki dkWy dj ;k fy\[kdj lquokbZ dk vuqjks/k dj ldrs gSa% **\[name\]**,
**\[address\]**, **\[phone number\]**

Hkonh;\]

**\[signature\]**

**xSj&HksnHkko fooj.k%** ;g crkrk gS fd ;fn vki le\>rs gSa fd vkils
vuqfpr O;ogkj gqvk gS rks D;k djuk pkfg,A la?kh; dkuwu vkSj vesfjdh
Ñf\"k uhfr foHkkx ds vuqlkj\] bl laLFkku esa tkfr\] jax\] jk\"Vªh; ewy\]
fyax\] vk;q ;k v{kerk ds vk/kkj ij HksnHkko djuk izfrcaf/kr gSA HksnHkko
dh f\'kdk;r ntZ djus ds fy,\] *;w,lMh,\] funs\'kd\] ukxfjd vf/kdkj
dk;kZy;\] 1400 baMhisaMsal ,osU;w\] ,lMCY;w\] okf\'kaxVu Mhlh 20250&9410
USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW,
Washington DC 20250-9410* dks fy\[ksa ;k 800&795&3272 ;k 202&720&6382
¼VhVhok;½ ij dkWy djsaA ;w,lMh, ,d leku volj iznkrk vkSj fu;ksDrk gSA

February 2006 Letter of Verification Results

Hindi Version Page 1 of 1