lnstructions: lTo be valid for i months lrcm dote ol issue)

Date: ll i.l f r'1T ryl I YT' ff-f

All detoits to be filled in Slock Lettets
To be ptinted on Plain A4 papet size ; Not required to ptint on letter head;

Resident's Details
ruon-nestdent lndian (NRl) l-l N"* Enrolment [-l upout" Request
l-l Resident I_l
Re tid e nt's Rece nI Co I ou t P hotag' o p h

Aadhaar Number Ctoss SQned ond Ctoss Stomped b/ lhe CetFhel

(For update onlY)

Resldent's Name

Full Name:

clo

House No./ Bldg./ APt:

Street/ Road/ Lane:

Landmark:

Area/ LocalitY/ Sector:

Village/ Town/ CitY:

Post Office: I

Di stri ct:

Statel

PIN Code: Signot!rc of the Resident/ fhumb/

finger lilPtessiaa
Date of Birth: [ITl1 ii,j 1',Ji I

I hereby certify above mentioned details of the resident

Att detoils to be t'illed in Block Letters

Name of the Certifier:

ii
Designation:

Address: i
affi+W,ro
Contact Number:
(Pleose tick appropriote bex below)
l, the certifier, am:
Gazetted Officer - GrouP B
Gazetted Officer - GrouP A

n Village PanchaYat Head or MukhiYa

lv1pl MtA/ MLC/ Muncipal Councilor

tl Tehsildar
Head of Recognized Educational lnstltution

n superintendent / Y,lardenl Matron/ Head of lnstitution

of Recognized shelter homes/ orphanages

stonlp of the Certtier

Signotu(e of the Cernlier

at sl- Nos' 23' 24',37 ',38 & 44; POR documents

at sl Nos ll & 14 DOB
NOTE: l his format Pol documents at sl. Nos. 17, 20, 21,22 &37;POA documents
is applicable for from time to time'
as amended
clocLrments at Sl. Nos. 4, 5 & 14 of Schec.lule ll of the
Aadhaar 1r^roimunt and Update) Regulations '2016'