eu 2.9HGwrf/ Self Declaration Photo of the applicant ‘with Bhoyfl wre Lib, pedeobucref anid, CarewniBaneraf Somos / pemb, 3/192-1 aga) cteit Conssriudlansra Osedlo adlegd DE Aufluenbsl srider Quut HGos Carguidorsr Mu wreix, creer apm G Sp SGMAN GU Oster sscudacr siooors gud Brot sss suenauiled 2 cisrenw crevreyid, OBE FUSSED stererTdd wenpSsciirsidens sterayid, prot safes Ssasdrecit/ aoomisc LsiroosG Ypbureronei coe Tororo AshuaGid ui sss, DeBus Beim_evens sib 177 wip 199-1 Sp corde oHons i fSunen paigscos CopAancreiiGid crorumg sCascir crong suGlenexCam@ 2 pShusflsdlerr@sr. Iam Thiru Periyasamy son of Tmt. Vediyammal residing at Door No. 3/192-1, street of 3/192,konangihalli Village / town of KONANGIHALLI, Taluk of Nallampalli, Dharmapuri District, Tamil Nadu State. The details furnished below by me are true to the best of my knowledge and believe and nothing has been concealed herein. | declare that | am well aware of the fact that if the Information and documents given by me are proved to be incorrect / not true in future, I shall be liable for prosecution under section 177 & 199 of the Indian Penal Code. ‘awa 7 ‘Gaui Name “cmp | Saisatiere papery /Relationshipror ‘SL No. Tage ‘deceased T P Pesyaamy 7 Sen = F Govindhaw o Sas > Palen co Daughter Signature of the Applicant / weypnudier eoaQuiniuid