-Acknevledgmant Numba Submission Date 101720801202241200008 13-02-2024 FORM 8 (See Rules 13(3) and (26) ofthe Registration of Electors Rules, 1960) ELECTION COMMISSION OF INDIA FORM NO. (Tobe file offce) Voter Application Form for Shifting of Residence/Correction of Entries in Existing Electoral Roll / Replacement of EPIC / Marking of PwD 7 “The Elec Regstation oct no. end Name of assembly Contry no. [ira Name OTMLajeut Orang Name of Faamertry Constveney » 1 Name (@ ob fer Unter Tertores not bang begs Assos) ~ ()Name ofthe ppcan-Thrwra Nayar EPICNo, _ wULos004s4 athe Detals. (eae xe sport @ [2] Aasraarnmvor Pb PP lo ©) [7] ‘amnotabietofunsh ny aches: Number because! drthave hahaa Number ate o,f St eleT*]:]*I:[s aia Mobile No.of FatherMotheany the rlave i avalable) Emalidof sl (0) ali of FateyMothet/Aey other relative arable) (@_eubmtappcation for ——_(iekany one of the following) 1. [2] siting of Residence fo) Correction of Entries in Existing Electra Ral (on) a Issue of Replacement EPIC without erection (1) 4 Request for marking as Person wit Disabilty 1. Applicaton fr Shitting of Residence have shed my residence and | requost that my name may be deleted ftom the prevous address and sited ote carrontadGrese mentioned belo. Irequet tata replacement EPIC may/b iasued tome custo change inmy address | hace rten my ols EPIC Present ordinary] House/sulding/Apariment No, | FlatNoe-1201| ‘Sueetares/Localiy salrpuria Serenity Apartment Residance(Full [RAs so 81201 Mobalaoad resorsjoab 288 Adress) Townivilage —] PINO 41/18 Main] RAT lesaérrcbotr iso atten siaest sdvcdoex PoaOfice | HsRlayou eaarent Keser PivGede [| séov02 Tehal/TelgalNlardal | HGRTTH Sector] Setaresc TOSS Distet | BB.MPISOUTID Heeot sae Karnataka sefattested copy of address proof ether in the name of applicant er anyone of the parents/spouse/adut chi Ileal envled wih as elector at the same address (attach ay one he documents mentioned below 1 Wet /Electicty/Gas Bil for that address (atleast 1 yea) 2 [a] Aadhaar card a Current passbook of Nationlized/Schedled Bank/Post fice 4 Indian Passport 5 Revenue Departments Land owningrecors including Kiean Baht. Registered Rent Lease Deed (case ena) 7. [1 Registered sole Deen cae of own house) Any Otar-(P. Speci)2. application for Correction of Ente in sting Elector Rol Pease correct my flowing details Electoral RVEPIC: (Wasi of enties/paticulas canbe coreced) (Puta tk Aobspin appropri bor blow) Copy of seatested Documentary Prof n support of clam tobe etached ‘SPACE FORPASTING (ONE RECENT +.) name 2 [] ender a Dob/ige PASSPORT SZE 4. J peaton pe s. LJ easton nae 6] tess unstoieo cover PHOTOGRAPH (450M 7.) Mobite Number 8 [| Photo X3.50M) SHOWING FRONTAL VEWOF The conectpariclasin he ent to be comecedane a nde: FULLFACEWTH — WHITE BACKGROUND a Fo (ONL IF FHOTOTO BE » | cance) [__Neme of Documentin supportof above claim ettached | | & eeyEyEYEYEEYSESeeee eres aera Ss_W_WO""0":S a | request that a replacement EPIC may be fasued to me dus ochange in my personal deta "herby turn my old EPIC “Application for lve of Replacement EPIC without correction request tat aepiacement EPIC may beissued tome as my orginal EPIC = (Putatickinappopratebox) 1] ws 2. [] bestrayed due toressen beyond contr! ike flocs fr, ather natural disaster ete a] Matietes herby tum my mutate) od EPIC (OR) Ihave atached copy of FUPolce report fr loet EPIC undertake to return the eater EPIC sued 1 me he same Is eeovered ata later tage “4. Applicaton for Marking Person with Disability Cetepory feisatilty (Tick he appropriate box for category of esabity) | tocamete Vil [J eat sounb [1 enter ie esroion Paceragect asain, |] & certcatestaced Tek appopiebo) — [] 68 TJ w DeccaRamiON | HERESY DECLARE that to the best of my knowledge and bellef that 1 am a eltizen of india and 1 am aware that making a statement or declaration Which Ie fale and which 1 know or bellee to be falée or do not believe to be trie Is punishable under Section 31 of Representation of the People ‘Ac1960 (43 of 1950) with imprisonment for a term which may extend to one year or with fine or with Both, Date 19-02-2024 ace: Bangalore “Accessility nsucion:- nthe ligt of provsens of gh o Percone with Disables Act 2016 and Rights of Persone wih Disables Rules, 2017, n cae of petcons wth Intell deabiy autem, cerebral paly and multiple sable ee, tgnatueorlfthand thumb impression of parson wth desi, oof signature or left hand thumb Impression of his/her legal guaran wl be roqured. ™ Submission of elfatested copy of mentioned documonts wl ensure speedy dlvary of eeriees. KOK OX ‘AcknowiedgementReceit for application x KOR Ackronledgemant Number $101720801302241200008 Date: 13-02-2024 Receive the application n Fam 8 of Shl/Smt/Ms. Tharana Nayar Name/Signtute of €RO/AERO/ELO “5 This is @ computer generated document and does not require signature **