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Annexure – II

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 FORM NO. – 1 ( See Rule – 4 )

Application form for issue of a Miscellaneous Certificate

R.I. Office ____________________

 

1.

Name of the Applicant

 

:

2.

Father’s/Husband’s Name

 

:

3.

Address

 

 

(a)   Permanent

 

:

 

(b)  Present

 

:

4.

Age (in years)

:

5.

Type of certificate is required

( Identity/ Nativity/ Legal heir/ Caste/ Income/ Resident/ Nationality/ Valuation/ Solvency/ Procession and any other certificate )

:

6.

Purpose for which the certificate is required.

:

7.

Particulars on the basis of which the certificate is required

:

8.

List of documents and affidavit.

( where necessary)

:

9.                   Declaration

I Sri/Kumari/Smt. _____________________________________ son/daughter/wife of Sri ____________ __________________ Resident of village _________________ P.O. __________________ P.S. _________________ in the district of ___________ do hereby declare that the information and particulars stated above are true to the best of my knowledge and belief and that they are exhaustive and I have not suppressed and any fact in case it is detected later on that any of the facts stated above are wrong or that I have suppressed some material facts I shall be liable for prosecution under the relevant law.

 

Place     :

Date      :                                                                                    Signature of the Applicant

 

 

 

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