SELF DECLARATION

I, Shri/Smt ____________________________________________ Son/Daughter/Wife of Shri.

__________________________________________ age _____________ resident of
___________________________________________________District ___________________
hereby declare that the facts mentioned herein below at the respective serial number are true to the
best of my knowledge and nothing has been concealed. I am well aware of the fact that if the
information given by me is proved false / not true, I will have to face the punishment as per the law
and the benefits availed by me shall be summarily withdrawn.

(Please mention the details as per the requirement / nature of the application made)

1. I say that ………………………

2. I say that ……………………………..

3. ……………………………………………

4. …………………………………………..

5. ………………………………………………….

6. …………………………………………….. ………………..

7. …………………………………………………………………………………………..

8. I say that this Self Declaration is made in order to produce to the Village Panchayat
Navelim, Salcete Goa for the purpose of ……………………………….

9. I say that if anything is found contrary, the Village Panchayat Navelim Salcete Goa is free to
initiate necessary action in the matter as per rules in force.

Name and Signature of the Applicant with

Photo Identity Card No.

Date:

Place:

Affix
Photo with
across
signature