‘Acknowledgment Number Submission Date :- 18-02-2024 FORM 8& eo (See Rules 13(3) and (26) of the Registration of Electors Rules, ees EZ °, 1960) “A (To be filled by office) Ma ELECTION COMMISSION OF INDIA Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of PwD The Electoral Registration Officer, No, and Name of Assembly Constituency Nof as] Nome Jamshedpur East OF No. and Name of Parliamentary Constituency, Nol | Name (Goa PAU FSi ories not haviog legislative Asser () Name of the applicant- BJAV BAHADUR SINGH EPICNo. _LRVS975289 ‘Aadhaar Details (Please tk the appropriate bo») @ ‘Aadhear or Number co) 1am net able to furnish my Aachaar Number because ! don't have Aadhaar Number Mobile No. of Self (on) ‘Mobile No. of Father/Mother/Any other relative (if available) Email Id of Self (or) Email Id of Father/Mother//Any other relative (if available) (submit application for (Tlek any one of the following) 1. [7] shitting of Residence (or) 2 [Yatton Enea xntina Electoral Roll (on 2, [] Issue of Replacement EPIC without correction (or) [1]. Request for marking as Person with Di ity 1. Application for Shifting of Residence Ihave shifted my residence and I request that my name may be deleted from the previous address and shifted to the current address ‘mentioned below. | request that a replacement EPIC may be Issued to me due to change in my address. I hereby return my old EPIC. Present | House/Bullaing/Apartmert Street/Area/Locality/ ordinary |_ No. Monalla/Rood Residence(F{it Town/Village] Post adress) PIN office code “Tehsil Taluge/Mabaal District sae | Self-attested copy of address proof either in the name of applicant or anyone of the parents/spouse/adult chil, if already enrolled with (Attach any one of the documents mentioned below *)- 1 Water/Electricty/Gas Billfor that address (atleast 2. [] Aadhaar Card year) 3 Current passbook of Nationalized/Scheduled 4. [5] indian Passport Bank/Post Office 5 Revenue Department's Land Owning records © [2] Reaistered Rent Lease Deed (In ease of tenant) Including Kisan Babi 7. [1 Registered Sale Deediin case of own house) Any Other (Pl Specify). Application for Correction of Entries in Existing Electoral Roll Please correct my following details in Electoral ROWEPIC: (Maximum of 4 entvies/particulars can be corrected) (Put a tick — anbspin appropriate box below.) SPACE FOR Copy of self attested Documentary Proof in support of claim to be attached. PASTING ONE 1) Name 2 [_] Gender 3 e RECENT Bese PASSPORT SIZE UNSIGNED a O Relation 8. oO Relation 6. TZ] Address coLor Type. Name PHOTOGRAPH 7 7] Mente 28. 1] Photo (somx3.s Number em) SHOWING. FRONTAL VIEW ‘The correct particulars in the entry to be corrected are as under: OF FULL FACE with WHITE sorovase7 (ONLY IF PHOTO 3203, lohiya tink path Baridin Basti, Jamshedpur, Jamshedpur _, JoBe BARIDI , 631017, East Singhbhum |, Jharkhand (9203, eer Fe craters we mae wef, ore, meats, MET) Name of Document in support of above claim attached 2 | Aadhaar Gara | request that a replacement EPIC may be lesued to me due to change in my personal details I hereby return my old EPIC 3. Application for Issue of Replacement EPIC without correction {request that a replacement EPIC may be saved to me as my original EPIC e- Puta tick in appropriate box) 1) Ey tee % [[] Restore due torenson bend conte dads, ther aie ester 2. (2) mutilate I neteby return my mulllated/ old EPIC (OR) | have attached copy of FIR/Police report for lost EPIC & | undertake to return the ealler EPIC Jeoued to me ifthe same is recovered at a later stage. 4 Application for Marking Person with Disability Category of disability (Tick the appropriate box for category of disability) Dear & I any other (Give description) Dumb Percentage of a % Certificate attached (Tick the CL Yes [I ne disabil appropriate box) [J tocomotve [_] Vieuat | HEREBY DECLARE thot to the best of my knowledge and bellef that I am @ citizen of India and 1 am aware that making @ statement or declaration which is false and which | know or believe to be false or do not believe to be true, is punishable under Section 31 of Representation of the People Act,1950 (43 of 1950) with imprisonment for a term which may extend to one year or with fine or with both. Place: Jamshedpur ‘Accessibility Instructions: In the light of provisions of Rights of Persons with Disabilities Act 2076 and Rights of Persons with Disabilities Rules, 2017, in case of persons with intellectual disability, autism, cerebral palsy and multiple disabilties etc., signature 6 left hand thumb impression of person with disability, or of signature or left hand thumb impression of his/her legal guardian will be required, * Submission of seilaltesied copy of mentioned documents will ensure speedy delivery of services Scan eons ‘Acknowledgement/Receipt for application Soiniecenae ‘Acknowledgement Number 52704808C1802241200020 Date; 18-02-2024 Received the application in Form 8 of Shri/Smt/Ms. BAY BAHADUR SINGH Name/Signature of ERO/AERO/BLO “t+ This ie a computer generated document and does not require signature