(For Official Use)
(Name & address of the Senior Officer acting as First Appellate Authority)
| 1. | Name of the Applicant | __________________________ |
| 2. | Address of the Applicant | |
| 3. | Particulars of the Central/ State Public Information Officer: (a) Name : (b) Address: | |
| 4. | Date of submission of application for seeking information | |
| 5. | Date on which 30/35/40 days from submission of application are over | |
| 6. | Reasons for appeal: (Please indicate separately for each question) (a) No response received within the specified period: (b) Aggrieved by the response received within the specified period (c ) Grounds for appeal | |
| 7. | Last date for filing the appeal | |
| 8. | Particulars of Information (a) Information requested (b) Subject (c) Period | |
| 9. | A fee of ____for appeal has been deposited in______ vide Receipt No._____ Dated _________(only if applicable) | |
Signature of Appellant
E-mail address, if any
Tel. No. (office)________
` (Residence)____________
Please attach :
(a) Copy of RTI application.
(b) Copy of the response received from CPIO with which the appellant is aggrieved.