Declaration By Local People For Delayed Registration Of Birth

We are the local people, residing at Vill………………………………………………………P.O……………………………………….

P.S……………………………………………..Dist…………………………………Pin…………………………………West Bengal.

do hereby solemnly affirm and declare as under.

A) That the exact date of birth of…………………………………………………………………..is……………………………………….

Born at Vill…………………………………………………………………………….………P.O…………………………………………………………

P.S……………………………………………..Dist…………………………………Pin…………………………………West Bengal.

B) That his/her father is……………………………………………………………………………………………………………………………

C) That his/her mother is………………………………………………………………………………………………………………………….

The above information are true and correct to the best of our knowledge and belief.

-:Witness Details:-

Sl.No Name of Witness Signature of Epic no of Address of Witness

witness witness
1
2
3
4
5

Signature of Child:……………………………………..

Signature of Father:……………………………………

Signature of Mother…………………………………… signature with stamp

Panchayat Prodhan

Date:

Place: