Application form for issue of transgender certificate of identity under
Rule Transgender Persons (Protection of Rights) Rules, 2020 read with
Section 6* / 7* of the Transgender Persons (Protection of Rights) Act,
2019 * Strike out whichever is not applicable
State Emblem
State Government of West Bengal
Office of the District Magistrate
Application form for issue of a transgender certificate of identity under Rule Transgender
Persons (Protection of Rights) Rules, 2020
(read with Section 6* / 7* of the Transgender Persons (Protection of Rights) Act, 2019
* Strike out whichever is not applicable)
1 Name
(i) Given name (in capital letters)
(ii) Changed/Chosen name (in capital letters)
(iii) Out of (i) and (ii), name to be printed in the certificate
of identity and in the identity card
2 Gender
(i) Assigned at birth
(ii) Requested in the application
3 Date of birth dd/mm/yyyy
4 Educational qualification
5 Present address
6 Permanent address
7 If there is a source of income, the annual income:
(i) Under Rs 1,00,000 YES / NO
(ii) Between Rs 1,00,001 and 3,00,000 YES / NO
(iii) Above Rs 3,00,000 Please specify the
amount:
8 Do you have any of the following documents? If so, please submit self- attested
photocopies of the certificates stated below.
(i) Date of birth certificate YES / NO
(ii) Aadhaar card YES / NO
(iii) PAN card YES / NO
(iv) Election Voter Identity Card YES / NO
(v) Ration card YES / NO
(vii) Passport YES / NO
(viii) Bank passbook YES / NO
(ix) MNREGA Card YES / NO
(x) Caste certificate (SC/ST/OBC/Others) YES / NO
9 Medical history (for those applying under section 7 of the Transgender Persons
(Protection of Rights) Act, 2019
(i) Have you undergone any medical intervention in the YES / NO
context of transgender transition?
(ii) Please give details
(iii) Name and complete address of the Hospital or medical
institute
(iv) Name of the issuing authority along with the date
(v) Any other medical status you would like to share
(vi) Have you been issued any certificate of identity under
Section 6 and Section 7 under the Act, or any other ID Card
issued by the State Authority before the commencement of
these Rules? If so, enclosed the same.
10 Any other information you would like to give
11 Have you attached affidavit prescribed in Form –2(d) and
4(1) of the West Bengal Transgender Persons (Protection of
Rights) Act, 2022 under section 5 of the -Transgender
Persons (Protection of Rights) Rules, 2019
12 Have you attached the passport size photographs? Yes/No
Enclosed: documents as mentioned in the application
Declaration
1. I declare that the particulars furnished by me are true and correct.
2. Information provided in this application will be treated as confidential and shall
not be shared with any person or organisation save the Central and / or State
security agencies, any other agency as provided by Law; and for statistical and
policy framing purposes.
Format of affidavit to be submitted by a person applying for certificate of
identity for transgender persons under Rule 4 of the West Bengal
Transgender Persons (Protection of Rights) Rules, 2022 read with Section
6 of the Transgender Persons (Protection of Rights) Act, 2019.
(Affidavit should be on Non-judicial stamp paper of Rs.10/-) Competent Notary Civil,
District (Name of the District), (Name of the State)
I, (Name), son/daughter/ward/spouse of (name of the parent/guardian/husband),
aged
(in completed years), residing at (address), (Tehsil), (District), (State) (Pin code) do
hereby solemnly affirm and declare as under:
1. I am currently residing in the above address.
2. I perceive myself as a transgender person whose gender does not match with the
gender assigned at birth.
3. I declare myself as transgender.
4. I am executing this affidavit to be submitted to the District Magistrate for issue of certificate
of identity as transgender person under Section 6 of the Transgender Persons (Protection of
Rights) Act, 2019 under West Bengal Transgender Persons (Protection of Rights) Rules, 2022.
.* strike out whichever is not applicable.
Deponent (Signature of the Applicant)
Verification
I, (Name), hereby state that whatever is stated here in above serial Nos. 1 to 4 are true to the best of my
knowledge.
Deponent
(Signature of the Applicant)
Tehsil
Date
Identified by me Before Me
Advocate Notary
Public
Form of certificate of identity to be issued by District Magistrate under
Rule 5 of West Bengal Transgender Persons (Protection of Rights) Rules,
2022 read with section 6 of the Transgender Persons (Protection of
Rights) Act, 2019
1. On the basis of the application dated dd/mm/yyyy to the undersigned it is certified that
Shri / Smt./ Km/ Ms (name) son / daughter / ward of Shri/ Smt. (name of the parent or
Guardian) of (complete residential address of the applicant) is a transgender person.
2. His / her birth name is .
3. This certificate is issued in terms of the provisions contained under Rule 5 West Bengal
Transgender Persons (Protection of Rights) Rules, 2022 read with section 6 of the
Transgender Persons (Protection of Rights)Act, 2019.
4. It is also certified that Shri/Smt/Km/Ms. is ordinarily a resident at the address given
above.
5. This certificate entitles the holder to change name and gender in all official documents of
the holder.
Date Signature of the District Magistrate
Place Seal
Form of certificate of identity for change of gender to be issued by
District Magistrate under Rule 6 of the West Bengal Transgender Persons
(Protection of Rights) Rules, 2022 read with section 7 of the Transgender
Persons (Protection of Rights) Act, 2019
1. On the basis of the application submitted to the undersigned along with a medical
certificate from the Medical Superintendent or Chief Medical Officer (name of the
Hospital and complete address), it is to certify that Shri / Smt. / Km/ Ms. (name) son/
daughter / ward of Shri/ Smt. (name of the parent or Guardian) of (complete residential
address of the applicant) has undergone medical intervention to change gender.
2. His/ Her birth name is ________________________ .
3. This certificate is issued in terms of the provisions contained under Rule 6 of the West
Bengal Transgender Persons (Protection of Rights) Rules, 2022 read with section 7 of the
Transgender Persons (Protection of Rights) Act, 2019.
4. It is also certified that Shri / Smt/ Km/ Ms. is ordinarily a resident at the address given
above.
5. This certificate entitles the holder to change name and gender in all official documents
of the holder.
6. Such change in name and gender and the issue of this certificate shall not adversely
affect the rights and entitlements of the holder of this certificate.
Date Signature of the District
Magistrate
Place Seal
