iz:i la[;k&5

Form-5

laΠlR;eso t;rs

No.
fcgkj ljdkj
Government of Bihar
;kstuk ,oa fodkl foHkkx
fcgkj ljdkj (DEPARTMENT OF PLANNING AND DEVELOPMENT)
vFkZ ,oa lkaf[;dh funs'kky;
DIRECTORATE OF ECONOMICS AND STATISTICS
tUe izek.k&i=
BIRTH CERTIFICATE
¼tUe e`R;q jftLVªhdj.k vf/kfu;e] 1969 dh /kkjk&12@17 rFkk fcgkj tUe e`R;q jftLVªhdj.k
fu;ekoyh] 1999 ds fu;e 8@13 ds vUrxZr tkjh fd;k x;kA½
(Issued under Section-12/17 of the registration of Births and Deaths Act, 1969 and Rule 8/13 of the Bihar
Registration of Births and Deaths Rules, 1999)
;g izekf.kr fd;k tkrk gS fd fuEufyf[kr lwpuk ewy tUe vfHkys[k ls yh xbZ gS] tks fd
¼LFkkuh; {ks=½----------------------------- rglhy¼vapy@iz[kaM½-----------------------------------------------
ftyk --------------------------------------------- jkT;% fcgkj ds jftLVj esa mfYyf[kr gSA
This is to Certify that the following information has been taken from the original record of birth which is the
register for (local area/local body) ......................................................... of tahsil...........................................
(anchal/block)...................................................... of District ............................................ of State : Bihar

uke@Name................................................................................................................ fyax@ Sex......................................

tUe frfFk@ Date of Birth..................................................... tUe LFkku@Place of Birth.......................................
ekrk dk uke@Name of Mother...............................................................................
firk dk uke@Name of Father......................................................................
cPps ds tUe ds le; ekrk&firk dk irk@ ekrk&firk dk LFkk;h irk@
Address of Parents at the time of birth of the child Permanent address of the Parents
........................................................................... ....................................................................................
........................................................................... ....................................................................................
............................................................................ ....................................................................................
iathdj.k la[;k@ Registration No....................................... iathdj.k fnukad@Date of Registration .............................
fVIi.kh@ Remarks(if any)......................................................
tkjh djus dh frfFk@Date of issue....................................
izkf/kdkjh ds gLrk{kj@ Signature of the issuing authority

izkf/kdkjh dk irk@ Address of the issuing authority

eksgj@Seal

^^ izR;sd tUe ,oa e`R;q dk iathdj.k lqfuf'pr djsa@Ensure registration of every birth and death**

0379 Raju 28.12.10