SPECIMEN AFFIDAVIT TO BE SUBMITTED BY APPLICANTS AS

PROOF OF DATE OF BIRTH IN CASE NO OTHER DOCUMENT MENTIONED IN

DOCUMENT NUMBER 2 OF TABLE 3 IN SECTION D IS AVAILABLE

I RAMA RAO J S/o W/o JAYARAMA RAO R presently residing atNo4 Old No 25 New 2 nd Block 1st Main
Opp KEB T R Nagar , Bangalore 560028 hereby state the following:
I was born on 28/01/1966 at Bangalore situated in the district Bangalore in the State of Bangalore I have no
Birth Certificate as proof in support of my place and date of birth.
I take oath and solemnly declare/affirm that the particulars furnished by me above are correct and that I have not
concealed or misrepresented any facts.
Place Bangalore
Date 29/10/2014
Verified on this 21 day of October of the year 2014 that the contents of my above affidavit are true and correct
to the best of my knowledge and belief, and nothing in material has been concealed there from.

Deponent

The contents of the affidavit have been read out to me.

Attested Signature and official seal of attesting authority