APPLICATION FOR PERMANENT RESIDENT OF TRIPURA CERTIFICATE

1. Name of the Applicant :( in Block Letters)

2. Address of the Applicant:

(a) Village
(b) Road No. (If any) (c) House No. (If any)
(d) Post Office (e) Police Station
(f) Sub-Division (g) District

3. Date from which the Applicant has been residing at the above address: ____/____/_______
4. Date of Birth: _____/_____/______ 5. Place of birth: .……………………………..
6. Nationality: ……………..………… 7. Educational Qualification: ………………………………
8. Name of Parents:
(a) Fathers Name: -

(b) Mothers Name: -

9. Name of Husband/Wife. (If married):

10. Permanent address of Father or Mother (in case father is not alive):
(a) Village
(b) Road No. (If any) (c) House No. (If any)
(d) Post Office (e) Police Station
(f) Sub-Division (g) District

11. Nationality of Father/ Mother: ………………………………………………………………………….

12. Whether father or mother is holding any Citizenship certificate: YES NO
(if so, produce an attested copy):
13. Whether the Applicant or his/her parents obtained any
YES NO
Permanent Resident Certificate from any other State.
(If so, produce an attested copy):
14. Whether Father or Mother or both is /are employees of the YES NO
Government of Tripura / State Government Undertaking working
Outside the state on deputation or transfer basis, if so : ……..
i. Name of the Department/Undertaking: ..……………………………………………………..
ii. Name of the Post: ………………………… iii. Place of Posting: …………………….
iv. Date from which Working: ____/____/_________
15. Whether Father or Mother or both is/are employees of the Central Government / Central
Government Undertaking / Private organization, if so : ……..
i. Name of the Department/Undertaking …………………………………………………………..
ii. Name of the Post: ………………………….. iii. Place of the Posting: ……………………
iv. Date from which Working: ____/____/_________

DATE: ____/____/_________ Signature of the Applicant

PLACE: ……………………………….
(Name of the Applicant)
 DECLARATION TO BE SIGNED BY THE APPLICANT

I, Sri/Smt …………………………………………………...……………………………………, hereby

declare that the statements made above are true to the best of my knowledge and belief. I
have not suppressed any fact and if subsequently it reveals that any of the above made
statements was false or misrepresented, the Permanent Resident Certificate3, if issued, would
be liable to be cancelled by the competent authority.

I, Sri/Smt ………………………………………………………………………………………, hereby

also declare that I have not obtained any Permanent resident certificate from any other State
Government or I have submitted any Application to any other Authority for the same

Signature of the Applicant ……………………………………………

DECLARATION TO BE SIGNED BY THE GURDIAN IF THE APPLICANT IS MINOR

1. That all facts stated in the duly filled in Application Form are correct and nothing has been
concealed therefore.
2. That my word has not applied or obtained certificate of Permanent Resident Certificate from
some other place.

Signature of guardian

Name in block letters:

Residential Address:

ATTESTATION BY ANY GAZETTED OFFICER

Sri / Smt / Ms / Kumari ……………………………………………………………………………………….

S/O, W/O, D/O ……………………………………………………………………………………………
resident of …………………………………………………………… is personally known to me and is
resident of Tripura for the last ………………………………… Years continuously. I have attested
the form of the Applicant for grant of Permanent Resident Certificate on my personal knowledge.
That the facts given by the Applicant for the issue of Permanent Resident Certificate are genuine.

Signature of attesting authority

Name in block letters:

Address with official seal:
Supporting Document for Permanent Resident of Tripura Certificate:

a) The applicant shall also produce the under noted documents along with his application for
Permanent Resident Certificate-
i) Age proof certificate such as Educational Certificate from recognized institute of the
applicant or minor, as the case may be, Admit Card of Madhyamik / H.S. (+2)
Examination.
ii) The applicant must submit the proof that the applicant’s parents were enlisted in the
voter list of 1971, in case the applicant’s father or mother is not a government servant.
iii) Birth registration certificate.

b) The applicant shall produce at least one of the under noted documents along with his
application for Permanent Resident Certificate-
i) Land Revenue Payment Receipt in the name of the applicant or his/her parent in case of
person of 18 years of age and of applicant himself in respect of minor.
ii) Certified copy of Electoral Roll showing the name of applicant to be issued by the
competent Authority.
iii) Certificate from the employer based on the applicant’s service record in respect of
employees working in Government/ Semi-Government / other organization in respect of
there wards.
iv) Citizenship Certificate of father/mother.

c) The applicant shall also produce at least one of the under noted documents along with his
application for Permanent Resident Certificate-
i) Proof of the applicant’s carrying on some business/profession/trade/occupation in the
State of Tripura like Trade License, Sale Tax Registration certificate, etc.
ii) Ration card containing the name of the applicant in case of adult and containing the
name of the applicant and of the minor in case of minor.
iii) Pan Card in the name of applicant.
iv) Bank Pass Book in the name of applicant.
v) Telephone bill in the name of applicant.
vi) LIC certificate and up to date premium payment receipt.
vii) Bank loan document.
viii) Birth Registration Certificate.
ix) Document including Municipal holding of the applicant
x) Permanent Resident Certificate of father/mother under new system.
xi) Registered purchase Deed in the name of applicant or his/her parent in case of
applicant of years of age or more and of the applicant himself in case of minor.
xii) Copy of ORR of Gram Panchayat / Urban Local Bodies, as the case may be, duly
issued by the Competent Authority.
xiii) Election Photo Identity card of the applicant.