lrstructions: All det*i1s to be filted in Slock Letters {To be valid for 3 months from dote of issue)

To be printed Gn plain A4 pafter size; Not reqLtired ta print an leXer heod;

;{ia to=l Eo' ig al
E4nl.,. Request

Aadhaar Number:
{For update only)
7,{ hiL,7't'l r L'l
Full l{amr: K ,fi,t

c/o: <'/ ,D ),E:? 1:) A V AU- V P 4 tN

House l!*./ Bldg./ Apt: 6 q
Street/ Road/ Lane:
\ ;y' fr' 3',A V:T: I-I I : N 4 e
La ndnra rk:
I ,c- H,U CH
Area/ Localityy' Sector: , f| ff \r kt v', L, 4
Village/ Town/ City; K tri N AT $;
Post office:

T I .tLw P'? uf_

3,8,\ , o.: P-q%\NM

\r ,8
Signature of ih= Rssd=EV
Thumb/ Finger lmp.essi3n

Name of the Certifier;

R. fi o{,e L A K .} H !t T
Designatian:
H.8,6 9 NA,A:s:T.F R'"
Office Address: . r U, .scHoor-
K, rJ : nr. cv. e. T. t-1, U,A
Ccntact Numtler: ,1 :t:&.t,Y-'b,L7 -l

I herelcy certify ebove mentioned details of the resident Checklist for Certifitr
and I am a.... (Tick approoriate box below) overwriring filled I signature nCertifier's
I i.io f] lssue date is Resident's dela]ls

fl Gazetted Ofi'cer - Group A I Resldert's Photo is cross signed and cross stam ped (pdper to phota or phota to paper)

f] v:tlage Panchayat llead or Mukhiya

fl cazetteC Officer - 6roup B rflr6DorrDrrtndrfl u.rr?,
E Me1 MLA/ MtC/ Muncipal Councilor o{.e.ErdB.udtfffl,
f] l"huit,iu,. t*oiOrrri - c3a ros.
ffUeal of Recognized Educational lnstituiion Eiorieera eirdusn
fl Super"intendentl Warden/ tulatron/ llead ol lnstitui:icn ,lg*ntri uns;.Lrir
of P.acognized shelter hornes/ Crphanages
fl rrrc offi.", Signature & Siamp of the Certifier

NCTI:Tlris fornrat is appl canle for POI docume nts ai 51. l\os. 17,20,21,22,31 &3L POA docunrents at Sl. Nos. ?3, 24,37,3A, 44 & 45; POR documents at Sl. Nos. 13
& 14 DOB docurirents at S1. Nos. 4,5,14 & 15 of Scheduie ll af tl-re Aadhaar (Enrolrnent and Update) Eegulalicns, 201[, a. amended [.o I iir]re lo rime.