Self Declaration

Shri/Smt/Miss Jagannatha Sahu, a 50-year-old resident of Khalia, Odisha, declares that the information provided in the application is true and accurate. The applicant acknowledges responsibility for the declaration's accuracy and understands the legal consequences of providing false information. The declaration is dated 25/10/2025 and includes a signature from the applicant.

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Self Declaration

Uploaded by

Muna Meher

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as DOCX, PDF, TXT or read online on Scribd

SELF DECLARATION

I, Shri/Smt/Miss Jagannatha Sahu Son/Daughter/Wife of Shri Jaganatha Sahu Age

50 year, Resident of Village Khalia PO Jogimunda PS Patnagarh Tahasil Patnagarh
District Bolangir State Odisha, do hereby declare that the information given by me in
this application form is true to the best of my knowledge and I have not suppressed /
misrepresented any fact. That, I am solely responsible for the accuracy of the
declaration and information furnished and shall be liable for action under section 199,
200 and 420 of Indian Penal Code and other relevant laws/ rules in case of furnishing
wrong declaration and information. Also, I am well aware of the fact that the certificate
shall be summarily cancelled and all the benefits availed by me shall be summarily
withdrawn in case of furnishing wrong declaration and information.

Date : 25/10/2025
Place : Khalia Signature of the Applicant/Submitter

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SELF DECLARATION

I, Shri/Smt/Miss Jagannatha Sahu Son/Daughter/Wife of Shri Jaganatha Sahu Age

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