Self-declaration Form

I.......................................................... �······························· ....................... .

Son/Daughter of shri /late.................................................age................... yc,,irs

Resident of................................................................................................... in

the District of .................................................. Tripura do hereby declare th:;rit the

information given by me in the enclosed documents (as per list below) is true to th:: lJcst of my
knowledge and belief and nothing has been concealed therein. I am well aw�n: of tfic fact that if
the information given by me is proved false/not true any point of t!me, I will be ii:lblc to face
punishment as per any pro•;ision of Law for the time being in force as wcJI as the h�ncfit availed of
by me or the benefit accrued to me shall be summarily canceJled.

List of documents in respect of which this declaration is made is as below:-

i)
"\
ii)
iii)
iv)
v)
vi)
vii)

Date:- Signature of the Applicant

Place:-