Election Commission of India
ϪÂa nj®jš Miza«
Application for issue of Replacement Elector’s Photo Identity Card (EPIC)
kh‰W th¡fhs® òif¥gl milahs m£il nfhU« é©z¥g«
A State/UT / khãy« / ôåa‹ Ãunjr« :
m. AC (No. & Name) / bjhFÂæ‹ v©Q« bgaU« :
District / kht£l« :
B Elector’s Particulars (To be filled by Elector) / th¡fhsç‹ étu§fŸ (th¡fhsuhš ãu¥g¥gl
M. nt©L«)
To / bgWe®
The Electoral Registration Officer /
th¡fhs® gÂÎ mÂfhç,
………………………… Assembly /
Parliamentary Constituency /
r£lk‹w bjhFÂ / ghuhSk‹w bjhFÂ
1. Name of Elector / th¡fhsç‹ bga®:
3. Father’s / Mother’s / Husband’s Name /
jªij / jhŒ / fzt® bga® :
FORM ID
got« ID
ECI-EPIC-001
Sir / Madam / mŒah / m«ikp®,
I request that a Duplicate Electoral Photo Identity
Card be issued to me as my original card is
lost/destroyed/mutilated or due to change of address. I
want to get a fresh card with my new address. I am
returning my EPIC to you along with fee for issue of
duplicate EPIC. My name is included in the electoral roll
for the above constituency. Particulars in support of my
claim for issue of duplicate EPIC are given below:
v‹Dila fhzhkš nghd / mêªJnghd / nrjkilªj mšyJ
Kftç kh‰w« nk‰bfhŸs¥glnt©oa c©ikahd th¡fhs®
òif¥gl milahs m£il¡F¥ gÂyhf kh‰W th¡fhs® òif¥gl
milahs m£il tH§FkhW nf£L¡ bfhŸ»nw‹. vdJ òÂa
KftçÍl‹ Toa kh‰W th¡fhs® òif¥gl milahs m£il bgw
éU«ò»nw‹. eh‹ v‹Dila th¡fhs® òif¥gl milahs
m£iliaÍ« k‰W« kh‰W th¡fhs® òif¥gl milahs m£il
tH§Ftj‰fhd f£lz¤ijÍ« brY¤J»nw‹. v‹Dila
bgauhdJ nk‰F¿¥Ã£l r£lk‹w¤ bjhF¡F c£g£l th¡fhs®
g£oaèš Ïl«bg‰WŸsJ. kh‰W th¡fhs® òif¥gl milahs
m£il tH§Ftj‰fhd v‹Dila é©z¥g¤Â‰fhd Ñœ¡fhQ«
Mjhu§fis rk®¥Ã¡»‹nw‹.
2. EPIC No. of
Original card (if known) /
c©ikahd th¡fhs® òif¥gl milahs m£il
v©. (bjçªÂU¥Ã‹) :-
4. Sex (M/F) : 5. Date of Birth (DOB)
ghèd« (M© / bg©) If not known then Age
in Years) as on 1st Jan,
201____......
Ãwªj njÂ.
(bjçahjg£r¤Âš
201... ... #dtç 1« ehs‹W
cŸsgo taij
M©Lfëš F¿¥ÃlΫ)
6. Address / Kftç
(i) House / Door number /
ÅL / fjéy¡f« :
(ii) Street / Mohalla / Road / Gali /
bjU / gF / rhiy / ÏU¥Ãl« :

(iii) Area / Locality / Ïl« / mikél« :

(iv) Town / Village / efu« / »uhk« : (v) PIN CODE /

mŠrš F¿p£L
v©
(vi) Police Station / fhtš ãiya« : (vii) District / kht£l« :

(viii) Reasons for applying for a Duplicate card / kh‰W th¡fhs® òif¥gl milahs m£il¡F
é©z¥Ã¥gj‰fhd fhuz«

Tick (  ) the appropriate box / cça f£l¤Âš ( ) F¿ælΫ :

1. I will collect EPIC from VRC/CSC / eh‹ v‹Dila th¡fhs® òif¥gl milahs m£ilia
th¡fhs® nrit ika¤Ânyh / bghJ nrit ika¤Ânyh bg‰W¡ bfhŸ»nw‹

2. I wish to receive my EPIC by Post (self addressed and stamped envelope enclosed) / eh‹
mŠrš _y« v‹Dila th¡fhs® òif¥gl milahs m£ilia¥ bg‰W¡ bfhŸ»nw‹. (Raéyhrä£l
k‰W« mŠršéšiy x£l¥g£l ciw Ïiz¡f¥g£LŸsJ)

3. I will collect EPIC from BLO / eh‹ v‹Dila th¡fhs® òif¥gl milahs m£ilia th¡F¢
rhto ãiy mYtyçläUªJ bg‰W¡ bfhŸ»nw‹.

( )
Signature of the applicant
é©z¥gjhu® ifbah¥g«

Tick (  ) the appropriate box / cça f£l¤Âš ( ) Date / ehŸ :

F¿ælΫ :

I hereby return my mutilated / old card /

eh‹ v‹Dila nrjkilªj / giHa m£ilia Place / Ïl« :
ϤJl‹ Ïiz¤JŸns‹..

I undertake to return the earlier card

issued to me if the same is recovered at a
later date / eh‹ v‹Dila giHa th¡fhs®
òif¥gl milahs m£ilia tU§fhy¤Âš
»il¡F«g£r¤Âš mjid x¥gil¤J éL»nw‹
v‹W cWÂaë¡»nw‹.
 For Official Use / mYtyf ga‹gh£o‰F k£L«

C Authentication for Issue of EPIC (To be filled by ERO’s Representative) /

Ï. th¡fhs® òif¥gl milahs m£il tH§Ftj‰fhd rh‹W (th¡fhs® gÂÎ mÂfhçæ‹ ÃuÂãÂahš
ãu¥g¥glnt©L«)

Part No. / ghf« Serial No. of ID number of Designated # Token No. or

v©. : Elector in Part / mªj Photography Location Receipt No. /
ghf¤Âš th¡fhsuJ tçir (DPL) or Common Service # nlh¡f‹ v© (m) uÓJ
v©. : Centers (CSC) / F¿¥Ãl¥g£l v©.
òif¥gl ika¤Â‹ (m) bghJ
nrit ika¤Â‹ milahs
v©. :

Register No. / Serial No. in Register /

gÂntL v©. gÂnt£oš tçir v©.

Verified by: /
rçgh®¡f¥g£lJ

Signature / ifbah¥g«

Date / ehŸ :
___/___/201___
D Acknowledgement of R- EPIC by the Elector / kh‰W th¡fhs® òif¥gl milahs m£il
<. bg‰W¡ bfh©lj‰fhd th¡fhsç‹ x¥òif

Received Duplicate EPIC on (Date) / kh‰W

Elector’s Signature Or Thumb Impression /
th¡fhs® òif¥gl milahs m£il bg‰W¡bfhŸs¥g£l
th¡fhsç‹ ifbah¥g« (m) ÏlJif bgUéuš nuif
nj :

- -
201___