| 1 |
Name in full (in Capital) |
|
: .......................................... |
| 2 |
Father's Name |
|
: .......................................... |
| 3 |
Mother's Name |
|
: .......................................... |
| 4 |
Nationality |
|
: .......................................... |
| 5 |
Address of the party in full: |
|
: .......................................... |
| House No. |
|
: .......................................... |
| Ward No. |
|
: .......................................... |
| Taluk |
|
: .......................................... |
| Village |
|
: .......................................... |
| District |
|
: .......................................... |
| Post Office |
|
: .......................................... |
| e-mail ID |
|
: .......................................... |
| Telephone No. |
|
: .......................................... |
| 6 |
Present Address of the party in full: |
|
: .......................................... |
| House No. |
|
: .......................................... |
| Ward No. |
|
: .......................................... |
|
Taluk Village District Post Office e-mail IDTelephone No.
|
|
: .......................................... |
| 7 |
Age and Date of Birth |
|
: .......................................... |
| (Sufficient proof shall be produced) |
|
: .......................................... |
| 8 |
Sex |
|
: .......................................... |
| 9 |
Occupation |
|
: .......................................... |
| 10 |
Previous marital status |
|
: .......................................... |
| (Married/Unmarried/ |
|
: .......................................... |
| Widower/Widow/Divorced) |
|
: .......................................... |
| 11 |
Whether any spouse is living (if yes, number ofspouse living)
|
|
: .......................................... |
| 12 |
Details of children, if any (in case of minors,specify)
|
|
: .......................................... |
| 13 |
Details of descendants, if any:- |
|
: .......................................... |
| Signature of the Party |
| Space for Office Use |
| |
Date of receipt of declaration |
|
: .......................................... |
|
Details of Documents/Records/ Proof requiredunder Rule 5(2)
|
|
: .......................................... |