DECLARATION BY 5 LOCAL PERSONS FOR GRANTING DELAYED

REGISTRATION OF BIRTH

We are the local people, residing at Vill ………………………………………. P.O.…………………………………………..…

P.S.…………………………………… Dist.………………………………………….. Pin………………………… West Bengal.

Do hereby solemnly affirm and declare under.

A) That exact date of birth of …………………………………………….…. is ………………………………….………

Born at Vill……………………...……… P.O.………………………………... P.S.………………………………...………

Dist.…………………………………….. Pin……………………………………….. West Bengal.

B) That his/her father is ………………………………………………………………………………………………………

C) That his/her mother is …………………………………………………………………………………………………….

The above information is true and correct to best of our knowledge and belief.

Witness Details:

Signature of
Sl. No. Name of witness Epic no.of witness Address of witness
witness

1.

2.

3.

4.

5.

Signature of candidate:…………………………………

Signature of father:………………………………………

Signature of mother:……………………………………

Date:
Signature with stamp
Place:
Panchayat Pradhan