ANNEXURE'D'

Affidavit
We 1........................................................
(Name of wife)
2........................................................
(Name of husband)
Solemnly declare and affirm as under:-
1- That we are married under Hindu Marriage Act marriage
Act/Rights/Customs and are living together as married
couple since......................(date of marriage)
2- That............................(Maiden name of wife)
would henceforth be known as
.............................(Name of wife after marriage)
by virtue of our marriage.
3- That our joint photograph is affixed below.
Date-------
Signature and address of
Deponents
1----------------------
2----------------------
 OFFICE OF THE EXECUTIVE ENGINEER, R.S.A.M. BOARD,
DIVISION-II, JAIPUR
It is certified that M/S Shri Balaji Constriction
company, Motlawas Teshil Dantaramgarh Distt- Sikar was
awarded Construction of widening & Up-Gradation of
Bharu to Luhakana Khurd under KUMS jaipur(grain)
consistency - Virat Nager Distt- jaipur in the above
work amounting to Rs. 60,50, 130/-only date of
commencement & stipulated date of completion as 18-09-
2009 & 17-03-2010 respectively The work has been
completed by the contractor dated 17-03-2010 The
following quantities has been executed by the firm on
march,2010
1. Earth Work - 3741.67 Cum
2. GSM - 2500.65 Cum
3. WBM - 1060 .00 Cum
4. PCC 1:3:6 - 30.50 Cum
5. CC M-30 - 800.70 Cum
6. RR stone CM 1:6 - 200.25 Cum
7. Hume Pipe - 8.50 Rmt.(1000mm)
47.00 Rmt.(300mm)
8. BT Work - 900.50 MT

Executive Engineer,
Raj. State Agri. Mrktg. Board,
Division-II, jaipur
 Annexure "A"

OFFICE OF THE TEHSILDAR CERTIFICATE

This is to certify that

Shri/Smt.-----------------------------S/O. or
D/O--------------------------
Resides------------------------------at--------------
His/her annual gross family income from all sources
for the year-----is Rs------------(Rs--------------)
This certificate is issued for the purpose of claiming
Interest subsidy under the scheme of the Ministry of
HRD, Government of India for pursuing approved courses
of studies in Technical & Professional streams from
recognized institutions for his son/daughter
Mr./Ms-----------------------------------------------
The signature of Shri/Smt-----------------------is
attested here below.
Signature ------------------------
Place:
Date: Signature of Tehsildar
Name:
Seal
 Annexure "A"

OFFICE OF THE TEHSILDAR CERTIFICATE

This is to certify that

Shri/Smt.-----------------------------S/O. or
D/O--------------------------
Resides------------------------------at--------------
His/her annual gross family income from all sources
for the year-----is Rs------------(Rs--------------)
This certificate is issued for the purpose of claiming
Interest subsidy under the scheme of the Ministry of
HRD, Government of India for pursuing approved courses
of studies in Technical & Professional streams from
recognized institutions for his son/daughter
Mr./Ms-----------------------------------------------
The signature of Shri/Smt-----------------------is
attested here below.
Signature ------------------------
Place:
Date: Signature of Tehsildar
Name:
Seal
 Annexure "A"

OFFICE OF THE TEHSILDAR CERTIFICATE

This is to certify that

Shri/Smt.-----------------------------S/O. or
D/O--------------------------
Resides------------------------------at--------------
His/her annual gross family income from all sources
for the year-----is Rs------------(Rs--------------)
This certificate is issued for the purpose of claiming
Interest subsidy under the scheme of the Ministry of
HRD, Government of India for pursuing approved courses
of studies in Technical & Professional streams from
recognized institutions for his son/daughter
Mr./Ms-----------------------------------------------
The signature of Shri/Smt-----------------------is
attested here below.
Signature ------------------------
Place:
Date: Signature of Tehsildar
Name:
Seal
 AFFIDAVIT
I--------------------------------S/O-----------------------------
R/O--------------------------------DOB----------------------------
being an a applicant for issue of passport, do hereby solemnly
affirm and state as follows:-
1 That the names of my parents and spouse are as follow:-
1 Father
2 Mother
3 Wife
2 That I am continuously resident at the above mentioned
address from Birth
3 That I am citizen of India by birth and that I have neither
acquired the citizenship of another country nor have
surrendered or been terminated/deprived of my citizenship
of India.
4 That I have not, at any time during the period of
fiveyears immediately preceding the date of this
affidavit, been convicted by any court in India for any
offence involving moral turpitude and sentenced in respect
thereof to imprisonment for not less that two years.
5 That no proceedings in respect of any criminal offence
alleged to have been committed by me are pending before any
criminal court in India.
6 That no warrant or summons for my appearance and no warrant
for my arrest, has been issued by a court under any law for
the time being in force, and that my departure from India
has not been prohibited by order of any such court.
7 That I have never been repatriated form abroad back to
India at the expense of Government of India/ I was
repatriated from abroad back to India at the expense of
 Government of India but reimburse expenditure incurred in
connection with such repatriation.
8 That I will not engage outside India Ian activates
prejudicial to the sovereignty and integrity of India.
9 That my departure from India will not be detrimental to the
security of India.
10 That my presence outside India will not prejudice the
friendly relations of India with any foreign country.

Date / /2010
Place Danta Ramgarh

Deponent

VERIFICATION
Verified on / / at Danta Ramgarh that the contents of the
above mentioned affidavit are true and correct and nothing
material has been concealed

Deponent
 ANNEXURE'A'
Affidavit
I............................................................so
n/daughter/wife of ........................................
Age.........years residing at................do hereby solemnly
affirm and say as under:
1- That I am an Indian National.
2- That I am unmarried and neither I, nor any of my following
close relatives-father/mother/unmarried
brother(s)/unmarried sister(s), are having any RO/SKO-
LDO/KSK dealerships of LPG distributorship from any Oil
Company. Or
That I am married and neither I, Nor any of my following
close relatives-husband/wife/unmarried son(s)] unmarried
daughter(s) are having any RO/SKO-LDO/KSK dealerships of
LPG distributorship from any Oil Company.
3- That I am a unmarried women above 40 years of age without
earning parents.
4- That I am widow and not re-married.
-----2------
 (2)
5- That I have never been convicted for any criminal offences
involving moral turpitude and/or economic offences (other
than freedom struggle).
6- I hereby confirm That I was never a signatory to a
dealership/distributorship agreement of any oil company,
which was terminated for proven adulteration/
malpractices.
7- That against item no- 13 of my application from details of
various sources of funds required for setting up and
operation of the KSK has been furnished. I undertake that
these funds will be made available for the purpose stated
above. In case it is found that the same is not made
available as and when required, the offer of dealership,
at any stage, can be withdrawn and that I will have no
claim/damages whatsoever against the oil company.
8- I hereby verify that what has been stated above is true to
the best of my knowledge and belief and nothing material
has been concealed there from. If any
information/declaration given by me in my application or
 in any document submitted by me in support of application
for the award of the dealership or in this affidavit shall
be found to be untrue or incorrect or false, Indian Oil
Corporation Ltd. would be within its rights to withdraw
the letter of intent/terminate the Operator ship (if
already appointed)and that I would have no claim,
whatsoever, against Indian Oil Corporation Ltd for such
withdrawal/termination.

Solemnly affirmed and declared before me.

This...........Day of.............

..............................
Signature and seal of
Magistrate/Judge/Notary Public

Signature of person making affidavit

(Name in block letters)
 ANNEXURE'D'
affidavit
We 1.Madhu Kumawat
(name of wife)
2.Dharm chand Kumawat
(name of husband)
R/o- Keshav Nagar Joshiyon ki Dhani se upar ka
mohala Post- Pachar Dist- sikar (Raj)-332729
solemnly declare and affirm as under:-
1- That we are married under Hindu Marriage Act marriage
Act/Rights/Customs and are living together as married
couple since 14/12/2000
2- That Madhu Kumawat would henceforth be known as Madhu
Kumawat by virtue of our marriage .
3- That our joint photograph is affixed below.
Date-------
Signature and address of
Deponents
1----------------------
2----------------------
 AFFIDAVIT
I S/O- -R/O- Teh- Dantaramgarh
Distt- Sikar -DOB-- being an a applicant
for issue of passport, do hereby solemnly affirm
and state as follows:-
1 That the names of my parents and spouse are as
follow:-
1 Father
2 Mother
2 That I am continuously resident at the above
mentioned address from Birth
3 That I am citizen of India by birth and that I
have neither acquired the citizenship of another
country nor have surrendered or been
terminated/deprived of my citizenship of India.
4 That i have not, at any time during the period of
five years immediately preceding the date of
this affidavit, been convicted by any court in
India for any offence involving moral turpitude
and sentenced in respect thereof to imprisonment
for not less that two years.
5 That no proceedings in respect of any criminal
offence alleged to have been committed by me are
pending before any criminal court in India.
----2----

(2)
6 That no warrant or summons for my appearance and
no warrant for my arrest, has been issued by a
court under any law for the time being in force,
 and that my departure from India has not been
prohibited by order of any such court.
7 That I have never been repatriated form abroad
back to India at the expense of Government of
India/ I was repatriated from abroad back to
India at the expense of Government of India but
reimburse expenditure incurred in connection with
such repatriation.
8 That I will not engage outside India Ian
activates prejudicial to the sovereignty and
integrity of India.
9 That my departure from India will not be
detrimental to the security of India.
10That my presence outside India will not prejudice
the friendly relations of India with any foreign
country.
Date 08/10/2009
Place Khanri

Deponent

VERIFICATION
Verified on / / at Danta Ramgarh that the
contents of the above mentioned affidavit are true
and correct and nothing material has been concealed
Deponent
 OFFICE OF THE TEHSILDAR,DANTARAMGARH (SIKAR)

ANNEXURE 'F'
SPECIMEN VERIFICATION CERTIFICATE (FOR PASSPORT
UNDERTATKAL;ONLY )

Photo
Reference Number ,

VERIFICATION CERTIFICATE

This is to certify that SH. RATAN LAL PALSANIYA S/O SH. PURA
RAM BY CASTE JAT, whose personal particulars are given below
has good moral character and reputation and that after having
read the provisions of section 6(2) of the Passports Act 1967,
I certify that these provisions are not attracted in case of
this applicant and I, recommend issue of indian Passport to of
him /her .Applicant has been staying at his/her address
continuously for the last one year .
Date of Birth - 05 MARCH 1987
Place of Birth - PUNIYANA
Educational Qualification _ B.A.
Profession(Govt./Private
Service/Others - PRIVATE SERVICE
Permanent Address VILLAGE- PUNIYANA, TEHSIL-
DANTARAMGARH, DISTRICT- SIKAR,
RAJASTHAN.
Present Address _ VILLAGE- PUNIYANA, TEHSIL-
DANTARAMGARH, DISTRICT- SIKAR,
RAJASTHAN.
Place- Dantaramgarh
Office Seal
Signature --------------------
Full Name - Rama nand Sharma
Designation - Tehsildar
I Card No. - ----------------
Telephone No- 01577-272333
Mobile No- 9829411130
 OFFICE-OF THE POLICE THANA DANTARAMGARH

ANNEXURE 'F'
SPECIMEN VERIFICATION CERTIFICATE (FOR PASSPORT
UNDERTATKAL; ONLY )

Photo

Reference Number ,

VERIFICATION CERTIFICATE
This is to certify that sh/smt/kum LAXMAN RAM Son of Shri NANU RAM
BY CAST JAT whose personal particulars are given below has good moral
character and reputation and that after having read the provisions of section 6(2)
of the Passports Act 1967, I certify that these provisions are not attracted in case
of this applicant and I, recommend issue of Indian Passport to of him /her
.Applicant has been staying at his /her address continuously for the last one year.
Date of Birth :- 10/11/1961
Place of Birth :- KARAD
Educational Qualification :- B.A.
Profession (Govt./Private Service/Others :- P. SERVICE
Permanent Address :- VILLAGE- KARAD TEHSIL-
DANTARAMGARH, DISTT-
SIKAR.
Present Address :- VILLAGE- KARAD TEHSIL-
DANTARAMGARH, DISTT-
SIKAR.

Place :- DANTARAMGARH
Office Address With location
Date :-
Office Seal
Signature ----------------------------------
Full Name---------------------------------
Designation -------------------------------
I Card No. --------------------------------
(Enclose a photocopy of I card )
Telephone No. (o)------------------------
(Res)---------------------------------------
Mobile ------------------------------------
 AFFIDAVIT
I----------------------------S/O--------------------------
R/O--------------------------------DOB----------------being an a
applicant for issue of passport, do hereby solemnly affirm and
state as follows:-
1 That the names of my parents and spouse are as follow:-
1 Father
2 Mother
3 Wife
2 That I am continuously resident at the above mentioned
address from Birth
3 That I am citizen of India by birth and that I have
neither acquired the citizenship of another country
nor have surrendered or been terminated/deprived of my
citizenship of India.
4 That i have not, at any time during the period of five
years immediately preceding the date of this
affidavit, been convicted by any court in India for any
offence involving moral turpitude and sentenced in
respect thereof to imprisonment for not less that two
years.
5 That no proceedings in respect of any criminal offence
alleged to have been committed by me are pending before
any criminal court in India.
6 That no warrant or summons for my appearance and no
warrant for my arrest, has been issued by a court under
any law for the time being in force, and that my
departure from India has not been prohibited by order of
any such court. ------2------
 (2)
7 That I have never been repatriated form abroad back to
India at the expense of Government of India/ I was
repatriated from abroad back to India at the expense of
Government of India but reimburse expenditure incurred
in connection with such repatriation.
8 That I will not engage outside India Ian activates
prejudicial to the sovereignty and integrity of India.
9 That my departure from India will not be detrimental to
the security of India.
10 That my presence outside India will not prejudice the
friendly relations of India with any foreign country.

Date 16/12 /2008

Place Danta Ramgarh

Deponent

VERIFICATION
Verified on / / at Danta Ramgarh that the contents of the
above mentioned affidavit are true and correct and nothing
material has been concealed

Deponent
 AFFIDAVIT
I Mangla ram Choudhary S/O Shri Tulsa Ram Choudhary R/O Chandelika
bas Teh Dantaramgarh Distt- Sikar DOB 03/06/1960 being an a
applicant for issue of passport, do hereby solemnly affirm and
state as follows:-
1 That the names of my parents and spouse are as follow:-
1 Father - Tulsa Ram Choudhary
2 Mother- Chooti Devi
3 Wife - Kamla Devi
2 That I am continuously resident at the above mentioned
address from Birth
3 That I am citizen of India by birth and that I have
neither acquired the citizenship of another country
nor have surrendered or been terminated/deprived of my
citizenship of India.
4 That i have not, at any time during the period of five
years immediately preceding the date of this
affidavit, been convicted by any court in India for any
offence involving moral turpitude and sentenced in
respect thereof to imprisonment for not less that two
years.
5 That no proceedings in respect of any criminal offence
alleged to have been committed by me are pending before
any criminal court in India.
6 That no warrant or summons for my appearance and no
warrant for my arrest, has been issued by a court under
any law for the time being in force, and that my

------2-----
 A2A
departure from India has not been prohibited by order of
any such court.
7 That I have never been repatriated form abroad back to
India at the expense of Government of India/ I was
repatriated from abroad back to India at the expense of
Government of India but reimburse expenditure incurred
in connection with such repatriation.
8 That I will not engage outside India Ian activates
prejudicial to the sovereignty and integrity of India.
9 That my departure from India will not be detrimental to
the security of India.
10 That my presence outside India will not prejudice the
friendly relations of India with any foreign country.

Date 28/11 /2008

Place Danta Ramgarh

Deponent

VERIFICATION
Verified on / / at Danta Ramgarh that the contents of the
above mentioned affidavit are true and correct and nothing
material has been concealed

Deponent
 AFFIDAVIT
I----------------------------S/O--------------------------
R/O--------------------------------DOB----------------being an a
applicant for issue of passport, do hereby solemnly affirm and
state as follows:-
1 That the names of my parents and spouse are as follow:-
1 Father
2 Mother
3 Wife
2 That I am continuously resident at the above mentioned
address from Birth
3 That I am citizen of India by birth and that I have
neither acquired the citizenship of another country
nor have surrendered or been terminated/deprived of my
citizenship of India.
4 That i have not, at any time during the period of five
years immediately preceding the date of this
affidavit, been convicted by any court in India for any
offence involving moral turpitude and sentenced in
respect thereof to imprisonment for not less that two
years.
5 That no proceedings in respect of any criminal offence
alleged to have been committed by me are pending before
any criminal court in India.
6 That no warrant or summons for my appearance and no
warrant for my arrest, has been issued by a court under
any law for the time being in force, and that my
departure from India has not been prohibited by order of
any such court.
7 That I have never been repatriated form abroad back to
India at the expense of Government of India/ I was
repatriated from abroad back to India at the expense of
Government of India but reimburse expenditure incurred
 in connection with such repatriation.
8 That I will not engage outside India Ian activates
prejudicial to the sovereignty and integrity of India.
9 That my departure from India will not be detrimental to
the security of India.
10 That my presence outside India will not prejudice the
friendly relations of India with any foreign country.

Place Danta Ramgarh

Deponent

VERIFICATION
Verified on / / at Danta Ramgarh that the contents of the
above mentioned affidavit are true and correct and nothing
material has been concealed

Deponent
 AFFIDAVIT
I Subash chandra Raigar S/o Shri Ram lal Raigar residing at
Kailash Date of Birth 15-07-1981 being an a applicant for issue
of passport, do hereby solemnly affirm and state as follows:-
1 That the names of my parents and spouse are as follow:-
1 Father Ram lal Raigar
2 Mother Gyani Devi
3 Wife Lalita Devi
2 That I am continuously resident at the above mentioned
address from Birth
3 That I am citizen of India by birth and that I have
neither acquired the citizenship of another country
nor have surrendered or been terminated/deprived of my
citizenship of India.
4 That i have not, at any time during the period of five
years immediately preceding the date of this
affidavit, been convicted by any court in India for any
offence involving moral turpitude and sentenced in
respect thereof to imprisonment for not less that two
years.
5 That no proceedings in respect of any criminal offence
alleged to have been committed by me are pending before
any criminal court in India.
6 That no warrant or summons for my appearance and no
warrant for my arrest, has been issued by a court under
any law for the time being in force, and that my
departure from India has not been prohibited by order of
any such court.
7 That I have never been repatriated form abroad back to
India at the expense of Government of India/ I was
repatriated from abroad back to India at the expense of
Government of India but reimburse expenditure incurred
in connection with such repatriation.
8 That I will not engage outside India Ian activates
prejudicial to the sovereignty and integrity of India.
9 That my departure from India will not be detrimental to
the security of India.
10 That my presence outside India will not prejudice the
friendly relations of India with any foreign country.

Date
Place Danta Ramgarh

Deponent

VERIFICATION
Verified on / / at Danta Ramgarh that the contents of the
above mentioned affidavit are true and correct and nothing
material has been concealed

Deponent
 AFFIDAVIT

I/we affirm that the particulars given above are in

respect of (name of the child)--------------------------
Son/Daughter of Shri-------------------------------and
shrimati----------------------------of whom I/We am/are the
presents/single Parents /Applicant Parent/Guardians
He/She is a Citizen of India His/Her date of birth /Place
of birth is---------------------------I/We undertake the entire
responsibility for his/her expenses I/We solemnly declare
that he/she has not lost surrendered or been deprived of
his /her citizenship of India and that information given
in respect of him/her in this application in true It is
certified that I/We am/are holding /not holding valid
Indian passport and the child mentioned is not included
in passport of either parent .
 Father Mother Notary Public
( Signature ) ( Signature ) (Signature)
OFFICE-OF THE CIRCLE OFFICER- RINGUS

ANNEXURE 'F'
SPECIMEN VERIFICATION CERTIFICATE (FOR PASSPORT
UNDERTATKAL; ONLY )

Photo

Reference Number ,

VERIFICATION CERTIFICATE
This is to certify that sh/smt/kum BANWARI LAL KAJALA Son of GANPAT
RAM whose personal particulars are given below has good moral character and
reputation and that after having read the provisions of section 6(2) of the
Passports Act 1967, I certify that these provisions are not attracted in case of this
applicant and I, recommend issue of indian Passport to of him /her .Applicant
has been staying at his /her address continuously for the last one year .
Date of Birth :- 15/01/1978
Place of Birth :- LAMIYA
Educational Qualification :- 10 th PASS
Profession (Govt./Private Service/Others :- NO
Permanent Address :- VILLAGE- LAMIYA TEHSIL-
DANTARAMGARH, DISTT-
SIKAR.
Present Address :- VILLAGE- LAMIYA TEHSIL-
DANTARAMGARH, DISTT-
SIKAR.

Place :- DANTARAMGARH
Office Address With location
Date :-
Office Seal
Signature ----------------------------------
Full Name---------------------------------
Designation -------------------------------
I Card No. --------------------------------
(Enclose a photocopy of I card )
Telephone No. (o)------------------------
(Res)---------------------------------------
Mobile ------------------------------------
 SUB-DIVISIONAL MAGISTRATE,DANTARAMGARH

ANNEXURE 'F'
SPECIMEN VERIFICATION CERTIFICATE (FOR PASSPORT
UNDERTATKAL; ONLY )

Photo

Reference Number ,

VERIFICATION CERTIFICATE
This is to certify that sh/smt/kum--------------------------------------Son of /wife
of /daughter of ----------------------------------whose personal particulars are given
below has good moral character and reputation and that after having read the
provisions of section 6(2) of the Passports Act 1967, I certify that these
provisions are not attracted in case of this applicant and I, recommend issue of
indian Passport to of him /her .Applicant has been staying at his /her address
continuously for the last one year .
Date of Birth ----------------------------------------------------------
Place of Birth ---------------------------------------------------------
Educational Qualification -------------------------------------------
Profession (Govt./Private Service/Others-------------------------
Permanent Address --------------------------------------------------
Present Address ------------------------------------------------------

Place
Office Address With location
Date
Office Seal
Signature ----------------------------------
Full Name---------------------------------
Designation -------------------------------
I Card No. --------------------------------
(Enclose a photocopy of I card )
Telephone No. (o)------------------------
(Res)---------------------------------------
Mobile ------------------------------------