ELECTION COMMISSION OF INDIA APPLICATION FOR DUPLICATE / REPLACEMENT / WALLET FRIENDLY ELECTORS PHOTO IDENTITY CARD (EPIC) DUE

TO (tick the appropriate box)

Form ID ECI-EPIC001C

Defect(s)

Loss / destruction / mutilation of image

Epic not being wallet friendly

State/ UT : AC (No. & Name): To The Electoral Registration Officer

...

Constituency.

Sir / Madam I am / was an elector of the constituency mentioned above and I was issued with Electors Photo Identity Card but (tick the appropriate box) image in card is incorrect spelling of my name is incorrect

spelling of my relation's name is incorrect gender is incorrect address is incorrect card has been lost

relation type is incorrect age is incorrect address needs change due to shifting card has got destroyed

Wallet friendly card is required in lieu of old card image in card is mutilated. I request that a corrected / duplicate/ wallet friendly EPIC may be issued to me
Applicants Current Details in Tamil Applicants name in English

in Tamil Fathers/Mothers/ in English Husbands name Place of Ordinary Residence (full Address) : House/Door No New : Old : Flat / Building Name : Block/Gram Panchayat : District : Police Station: Electors Photo Identity Card NO : Applicants details as in card in Tamil Applicants name in English Fathers/Mothers/ Husbands name in Tamil

Street / Road /Locality/Mohalla : Municipality/Ward No. : Town/Village : Post office : Pin Code : Date of Birth (DD/MM/YYYY)

in English Place of Ordinary Residence (full Address) : House/Door No. : Flat Name / Building Name :

Street / Road / Locality / Mohalla : Municipality/Ward No.

Block/Gram Panchayat : District : Police Station: Electors Photo Identity Card NO Applicants/Electors Photograph

Town/Village : Post office : Pin Code : Age

I am submitting two copies of my recent passport-size photograph along with my signature/left thumb impression across one photograph. Two passport size photographs are pasted in the space provided-one signed across and the other unsigned-at my own cost for preparation of Photo-Electoral Roll & Electors Photo Identity Card. An attested photocopy of a photo-bearing identification document is also enclosed. Affix one passport size (3.5 cm x 3.5 cm) colored photo here (This photo should be signed across, i.e. part of the signature on the photo and part of the Form )

Affix one passport size (3.5 cm x 3.5 cm) coloured photo here (Do not put your signature on this photo )

In support of Photograph-Passport, Driving License, PAN Card, and Service ID Cards issued to employees by State/Central Electors Photo Identity Card./PSU/Public Electors Photo Identity Card.Co., Passbook with photograph issued by Public Sector Bank/Post Office, Students Identity Card issued by Recognized Educational Institution., Pension Document, Railway Identification Card, Freedom Fighter ID Card, Arms License, Electors Photo-Identity Card (Electors Photo Identity Card) issued, if any [Note: Please enclose attested photocopy of any of the above photo-bearing documents for verification of the photograph. In case the document is self-attested, then show the original at the time of submission of the Form in person. Declaration I hereby declare that the facts and particulars mentioned above are true to the best of my knowledge and belief. Also I am aware that I am liable for penal action for giving incorrect information in this application. Place : Date : . Applicant / Electors signature or left thumb impression Note: 1. If name is not there in electoral roll or /and shifted from outside the Assembly Constituency, then claim has to be given in Form 6 for inclusion of name in the roll; if shifted within the constituency then application has to be given in Form 8A. 2. For correction of name in Tamil or in case of wrong image, Form 8 has to be given 3. In case of request for replacement / duplicate Electors Photo Identity Card due to change of address, lost / misplaced / mutilated Electors Photo Identity Card or for wallet friendly Electors Photo Identity Card in lieu of old card, the amount prescribed has to be remitted by the applicant. For Office Use ** CERTIFIED that I, _____________________, s/o__________________, ________________ (designation of verifying/attesting officer) have verified the authenticity of the applicants photograph with original passport/driving licence/arms licence/others (specify name of document and get one photocopy if not already attached) or on the basis of the statement of Shri/Smt.__________________ (name of the person) supporting the authenticity of the photograph, whose name is included in the electoral roll. The application for Duplicate / Corrected / Wallet friendly EPIC is accepted / rejected. Signature of ERO Acknowledgement of **Corrected / Duplicate / Wallet-friendly EPIC (by the Elector) Received **Corrected / Duplicate / Wallet friendly EPIC No and Date : Electors signature / left thumb impression : ERO / AERO signature with date and designation : ** Strike out the inappropriate alternative