GY ere raw steyate tee yt? ? covermmen of Puna — ee". PB me Z Department of Health and Family Welfare fras w3 ufees afore ferro Delayed Registration of Birth Hon nedifede a Be ofrrenT ‘sera / fines & a Name of Block / Tehsil INSTRUCTIONS / |. The *Personal Details” section s non-editable. To modify Personal Details, please update your profile inthe application and then download the Form again evacars 838 er rat hres lta re | eves a 8 wat Hates Ta we, PK xadnnit ts § tetas 308 Gera zon zsbnG 33) 2. Allfelds highlighted in red are required felds / fra? hss es da oe aioe 3 w® an, Ga a Hg | 3, Please refer the last page fora Ist of required documents / fra wad ng encréat & yeh 8 wc I 22 | 4. Totype'n Punjab, peas instal Punjab keyboard by gong to Control Fane>> Region and Languages >> Keyboards and Languages lick "Change Keyboards and select "Punjabi Select Punjab frm the taskbar / Ut 9 St ea wi, st ‘ise rg sor 8 fre Ot >> snd ign >oetea ed gen Re ne, ge Sew 3 wee aR debe Te zmewad tint 8e%3 | 5. the instructions and Rules are avallabe at wor Punjab goin / 78 fos w2 fxn war: Panjab govin ATE 3 | 1 Personal Details / fewastas 2oe" | ____ Personal Data / fewastars se" Fillin English | [Wrst Rosa Mr. Mrs. / st Ms. 7 i a 2. | Chinen’ rst Name / rata utara? 3._| Citizen's Middle Name / wrafea e Feawaa? | Ctzens ast Name /arafea o oredh at | 5 Gender / fat Male / WaH Female /¥ia3 : ae 7 z Date of birth /we54 feel Father's First Name /fust e ufos oF Father's Middle Name / Rist & Peeara at Father's Last Name / fist er nrech at Mother's First Name / W'S" @ ufaet at 11. | Mother's Middle Name / War et Pewara at [7227 [Mothers tast Name / He ered ot Page 1 of 15“ere wears Government of Punjaty ine Re 33.__[ Place of Birth / on wT 14_| Marital Status / Pewra Fah 75. | Spouse Name / wat / wat erat 16. | Email 1D / vite wre a 17. | Phone Number /@5 #6 18. | Mobile Number / Farts 32 to, | Permanent Account Number (PAN) / ar wat a (i) 20. , | Voter 1D Card Number / @ea wel Hares oes 21. | wadhaar Number (UID) / ura as (q wet wt ) ‘Aadhaar Enrollment Number (if Aadhaar not 22. | issued) (otra festa dra (Fara wera ss wt ‘edt Senn st) 23. (a) | Passport Number / wHUse Seo 23. (b) | Date of issue / wat was of frst 23.() | Valid Upto 7/2 3a 2037 23. (d) | Place of Issue / wel aaa St at 24, ‘Below Poverty Line (B.P.L.) Card Number / argh and a8 (et. ul Ae.) er aes oS Permanent Address / ta" us 1, | Address 1/ us" 1 2 Address 2 / ua" 2 3. Address 3 / ua" 3 Rural Areas /g 3a Urban Areas /ufudl Baa 4 Vilage 7 Rls Ward Number /€33 83 5. Block / ware City aa 6._| Tehsil “ati District / Page 7. | District / Rg State / Hee (3H) 8. State / Hee (37) PIN Code / fis 23 9, | PINCode / fis a Page 2 of 15S Ue AeaTS LY: SES Goveramant of Punjab a eesti cat Address / daw UST 1 | Address 7s" 2 = 2 | Address 2 7st 2 Z - 3, [Address 3 WSS : Rural Areas / tg Urban Areas /wiadh 23e 4 [Village 7 Ris Ward Number / @aa @aa 5._| Block/ ware Giy [a 6._| Tehsil stants Distriek / Fae iz | 7. _| District / erg ‘State / Rez (37%) 8,__| state /Wee (77) PIN Code / Risa [a [Pmenie Rare 2_Service Details / WETS" tron Vita aa P28 | Application Details / wart & ae" a 1. | Application No, warts - 2. | bate of Application / mrav tt © Suwidha Kendra /ifear es | 3. | Mode of Delivery / mrenfeaft er © Gram Suwidha Kendra / aw afew tea By Post / a wnat 4. | Application processing Office / wap wae Bass 5._| Applicant s Name / Petara era | 5 | Applicant's Relation with Citizen /Pabara = arate wero 7. | applicant's Address / fara er (a) | isthe Bith already Registered ?/Rivau vis’ 3 [o Vesa wad? © _No/at f(b) | IFVes Provide birth Registration Number / Waa Page 3 of 15 /Govemmem of Punyaty § are Fees apron ten ea ee ~~ Late Registration of Birth Events / won Hadad feu on G Be airmenT 1 | Rural / Urban / Ug / Bf 2. Application Type / met or 3._| ison availabilty Cericate issued /at 5 ves n@Bfattsch adits wre ast atten 32 Bt aa « Grandfather's Name/ 72 = 3t Address of Parents at the time of Birth / 70H FAT ear fg rust © | peason for late entry / Be Rest aawee wares an Birth Related /wervidas: 4 Date of birth / Wax fst 2. | Sex ofthe child / 3 oar orm a Name of the child / #3 =" ot 4. Father ‘s Name /fust 2 5m 5_| Mothers Name 7 war ean 5. address ofthe Parent atthe Time of Birth / &@ @ Fos fr erst 7. | Informants Name and Address 7 Guavara er 5H nous if [8 | Age of Mother at the time of bith of child / #8 & — |r wi * Name of helper at time of birth / #2 et Derfen nit narfea et at a 10. | Weight of Child at the time of Birth / HoH 2 i He era 11] Place of Birth / 75H mar © Hospital /aMUsTs Nursing Home / afin 12. | Order of Birth / Paes Sar | 13. "| Type of Assistance given by Dai / Hospital / =e / nse 28 EF a rate a Rao Page 4 of 15& aoe od eerste ae Part—3_ Uist of Required Documents (If birth is being registered within one year) Tiga enIeat Ct UT (faa Hon fea re 2 feo wan aaerfior a feo a) ‘Name of Document | Barwa? Whether Mandatory / Optional / gat / feet ‘Scanned Copy of Affidavit attested by Magistrate Or Notary Public/ Aftrete wt Bech 28 norcw he ren firs es ar Mandatory / #93 ‘Scanned Copy of information form No. 1 for Birth / wor eel read gan sea 1 et AR amt Mandatory gat Scanned Copy of Proof of birth lke hospital / ‘using home report or immunization card ete (in Case of Birth) / went ar mS fe fe ORT / wah auc fata Wt diaaas was oh ws ah fo Cas For eo aTe IT) Mandatory / agit Scanned Copy of Report of Registrar that Birth event is not registered / afaneas Hf fallae fa aH | wa at tem Be aru Mandatory / ‘Scanned Copy of birth / school certificate of | brothers/sisters of child / #8 2 wat / 32 2 HoH / ge wdifede wl wes aft Optional / fees Page 5 of 15+: Cnet List of Required Documents (If birth is being registered after one Year) /Hgst CAT SH Gt Hut (as OH fet We 3 we van aati a faa" a) Le etm Shee Name of Document /ena@a Bat ‘Whether Mandatory / Optional / #gat | fete Scanned Copy of information form No. 1 for Birth / sim wel wears eran as 1 ot Ras amt Mandatory Seanned copy of Proof of Birth lke hospital / ‘using home report incase of institutional births and seanned copy of school certifieate or passport or immunization card or driving license in case of 4domiciary birth or any other proof which shows date and place of birth. / Hau BET fia far THs (sotto dy ft false ot nate ani Aas HOH TRUSTS Ra Ste at ge Radieae, Zara wag, unilse at sate Brin Ras HM US PES ‘fe 3 st wt aC Te SH hf ETS wreae 82] Mandatory gt ‘Witnesses of two credible persons like Sarpanch/ Panch / Municipal Councilor (Mc) / Member of the Legislative Assembly (MLA) / Member of Parliament ( MP) or Gazetted Officer under state rule 11,/2 ferent femal fr@ rt, vs, Remus rer (x,t), RecraRsT B eH (De ‘Re 2), rire we Hen (RU wee ge 11 Batis ames were ot arect Mandatory / gat Scanned Copy of Voter card or Ration card for proof of residence / fearon 2 nas wel Bee ares wt SES aes Ui Ras ah Mandatory / Scanned copy of Non — availabilty certificate pertaining to the year of occurrence of event / Hone wes HA Bs meB Raise Raeae Ges ant Mandatory / 8 | Selt-declaration /w® wire Mandatory / Page 6 of 15a= Sas le x ‘Scanned Copy of birth/schoo! certificate of brothersisisters of child. / #8 2 gar /8e @ HoH / ge naditeae ots art | Note: At the time of upload/submission of e-Form, please make sure to attach the mentioned documents. Be Mean hms / Wi aaT es Brat Saran fee fod D8 exe GSE ITE aS BEL Page 7 of 15? : pe “Mara Haars eed bearers Pung aa ese eae ¢ frites fewast Garcia (SH) 8 . ss hes, senminonnenA, aaa wae aa aT 7 Uae het . (nore) ft fea wren / at 2 ra sor | fend eran ee RS _ fhe far fer HRS vo Wear Hidas Baw afirers e ‘weay fell wan adh 8 ft fem SEO oN wr fea Be aeneans @ 3a3 Maz / fawn onli wan AeSES wet hres age aah ot | Qudas came Sa we eh save ch were grr fase Ae 8 eaAT TT (ores Rasa m8 fic Ra) srs Ais tems sa / ts. B./ i oe | ae we Page 8 of 15Government of Punjab be RR toe : wee ae ® sa Nish seh. os) fa. 1-85 eB wig fs : weet Bt fe fa Qudars 198 WB w/e er / et et | 4, fears. so BENG snes OUD RE PETA (Rea) s (ur few de wel Ris wr oni nd seth Dn at MLE fe de we Fe sp waurion 7) Po a | 2, fea fa fen Denton fe eet sen RRL (se Wt OH BEA) | 3. fea Rafer aan | eal 2 re fern sida ofirears, Hox 3 is @ wes fell a Uay was! wae Tro eam at werent a fie 2 | (aUTS Res OP wo! el OR 2 Raas mens feos Eon ot sas e ras eaMee) | 4, fea fa forma | wach 2 ered ws er Ns . BRAT oa fag od orod ua eR. atures 1 fag. 6. fea ieee he nt cs Beef | 6. fea fa fon arsenal won Rear ares eon fee a3 wan aot D| i 7. fea fe Be efits rit A ah args | fsa as Gat eh wes ata / att 3 fen Be HH Meera Hit el oad dors wae Ge el Bows ot | 8. feafater ufsers fee Fe. san FH Rn Kept | at ata Dot wae ae won sachs Wea ‘Sa waarterrf) ori vee BIT fee ter’ | 9. fe fee @ Hari few est a aos nS fea Hr ate ae so Far 2 | 10. fe fe fe eras or raw aCHPaR vise eet urdter 2 nd fea fait daz arr wet ‘SatoradtD| Page 9 of 15) wer Day ? vine Faas &. eect Goverment of Punjab — Ss aa - RED Be ohnedas Oe ald eHaeH fs won Se mars wae fee Pada fer ais 3 efas vt fe ee en oh Be fas Gus Hoe RES me an ears Fe a A ata ar se at | sata sees POA evn SAGE aera a ft Qudas m3 aie ener Re FE BT Re wreardh 8 fener mega waRS 2 8 fer Rage eh etic Ram 8 | fe ts 3 are Ff Ras AS wor HUH ae HT gah TTD STA aegis ws rare rftera Setar fea 8 ie yah HOT @ mere 3G HB ers Haw (summarily) 932 wand red | ers Page 10 of 15aedtor fers ~ Ysa sch hes et : Be fst mer fos weet fase at fea far Qudas R93 U2 fatale Akt ena at | 4. fea fa eb Bait (Beams rs fs ee er aro afar Do Ht OTS PS Ie we a BT ‘wearreng rd et remy fame ft | 2, ef fe theron feta ee rea (Pra wat Rs ed He Be) | 3. fea far fen Baa fase et aon feos situs ofAcOS, HOH 3 Hs, @ ease fet gs way wast waa FA Hs ‘wan dt aoerfonn w ftron 2 | (amare fee OB Hot wel GRR Nahas en Reo von oT wIeES wt was woreE)| 4, fe fr fom ar | a 2 wre! wae is afi / Rign a area wee fUB..... ™ 5. fea far fen oxervenel cf &e won aftnedes Tet etre a | 6, fea fer fen araarvera enon fteaa aaa ean fide a3 ot eon aot | 7. fea fea Be ofan Heth A St args / fount os, Gat ef urs aatan atalt 2 fem Be weH warn sil wee? ard tn wat zoe Ge a fone ot | 8. feu fe few ufera ft ais . Afar fot 3 HOM foe 8 | shot et sede dat cowed ae 3 oN sate wero fa(ssavezct) OM feat 9, fea Fir fran fo @ areas Os ed fer ar teat Ro fe 2 | Page 11 of 15 @ uew reas Qian ® Goverment of Punjab is ae% ‘Government of Punjab ae? ome 10, fea fr fen wxaiiare er HH HaCHER .. see HIS BTC De fea fa ae a Batter oat 8 | 11 ee eh Be afer Ue’ ea eet Aes ean Sat gma weer Po fact at ne fen ae 3 was oT SS Fon A Be attoreams uds wore fea Gre mer feo fee fall et ag at ach wash vise ot 3 | ners ——— ep ae ire fea inet agevaael af fa Gudea wa Set Ensen fea Rd quer dt react od frre ogHTS egAS mig fer fa ae A euro a fired | A feo ats Fare ofa tas 33 goss AES ant goo YS TET BAIS arb che Here aahes Bear Seta wd wah yoT oer e wera BG Hes ws ITT (summarily) 33 wow re | ews Page 12 of 15(By ars rears Bosse Government of Punjab e . ry otere okra Heo fea fr nar aaa wa ass aus fils Ba far we | 41. rah fron er ft | fl (Qua wore HR rar we Ba 3 aPC | fea Qe mrs 3 visa 3 rarer DAE AS oH Foe", we eras ean was eh Be act) (@) nfaa / Rig er a (on) fea ira & ats (et Per fears Peer 3 ) To UaH (wen =r aH fis ae ) 9, fast er ile uc (yar aftr feo tra wat afar are fe fr ars HRT Sar uo fy dew 6 A aS fa 4. nara Dion urs (yar ats fitkow ua waR air are fae fa Rare Hat dau Uy aes 6 Mens fie 5, far er ta (aa ae ft tft) He rot oH os fig a fe IB eS nts eM ao sr nS WR A Pa eB PG TR 2 FO At ee 3 HO fre a Uae fatlwr we Page 13 of 15oo Kina 8. wear er fat (Bara ah fats act 3 8 fi). 6. fea Rts SH Gira (UB Bt Few) (Bare Bf 3 frre ere fea Sftoor 32 UR Pera A aA Ga wow A wa), 7. fer eH HA HTS" a Ours (ys FST fee) 8, fen SB Fits Ware IR HA Soo oh fresh... srt Bt eis fa (0 fst rer far 2a ft =) 0 Hiner rad co. Hine fof wt dtoroaret 0 waze, san, treat yus tees © vongas new rarfew (eet) o fasera tae 10. Bd er ada (Is Pestkowr fleas fea star Fre) © seat © SB niles wore o Bamun/ Saga grat 11, FO At (TEP AE 12, ara = Rt (Taft FE).pre Ages ata enetn ee CGovernmisnt of Pura ae Nace ‘finer erat fer Te a fg stants vag fis wea eH afreane tes BATHE Fos RCSAS CH a eh ct far o var fens oH oo o anus Fire afanrcara wa »8 oH Page 15 of 15