Annexure-IV
Declaration Form
(To be submitted along with Form 6/Form 8 for enrolment as a new Elector/shifting
from outside the state)
Applicant's Name:
Mobile Number:
Address:
Details of the Elector in the Electoral Roll Details of the Relative, whose name is given in
of the last SIR (if applicable) the previous column, in the last SIR
Elector Name: Name:
EPIC No. (if available) EPIC No. (if available)
Relative’s Name: Relative’s Name:
Relationship: Relationship:
District: District:
State: State:
AC Name: AC Name:
AC Number Part No. Sr No. AC Number Part No. Sr No.
Father’s/Guardian Name
Father’s/Guardian EPIC No. (if available)
Mother’s Name
Mother’s EPIC No. (if available)
Spouse’s Name (if applicable)
Spouse’s EPIC No. (if available)
( i) I have not acquired the citizenship of any other country.
(ii)IamapplyingforinclusionintheElectoralRollthroughForm6,andmynameisnotincludedinany
other Assembly Constituency/Parliamentary Constituency. ☐
Or
I am applying for inclusion in the Electoral Roll through Form 8 on shifting. ☐
(iii) I am aware that making the above statement or declaration in relationtothisapplicationwhichis
falseandwhichIknoworbelievetobefalseordonotbelievetobetrue,ispunishableunderSection31
ofRepresentationofthePeopleAct,1950(43of1950)withimprisonmentforatermwhichmayextendto
one year or with fine or with both.
Signature/Left Thumb Impression of Elector with date
BLO’s undertaking:I have verified the above detailsfrom the electoral roll(s) of the last SIR.
BLO’s Signature
BLO’s Name and Phone Number
Information Sheet for Declaration Form
pplicantscanchecktheirnameandthenameoftheconcernedrelative(s)inthepreviousSIR
A
Electoral Rolls at [Link] to provide the details in the Declaration Form. For
help, applicants can connect with the concerned BLOs. ERO will issue notices to those
applicants whose previous SIR Electoral Roll(s) details provided in theDeclarationFormare
either unavailable or do not match the database. Upon receipt of notice, the applicant to
provide the documents based upon the following categories:
● If born in India before 01.07.1987
○ Provide anydocument,forSelf,fromthelistgivenbelow,establishingthedate
of birth and/or place of birth.
● If born in India between 01.07.1987 and 02.12.2004
○ Provide anydocument,forSelf,fromthelistgivenbelow,establishingthedate
of birth and/or place of birth.
○ Provide any document, for Father or Mother, from the list given below,
establishing the date of birth and/or place of birth.
● If born in India after 02.12.2004
○ Provide anydocument,forSelf,fromthelistgivenbelow,establishingthedate
of birth and/or place of birth.
○ Provide any document, for Father, from the list given below, establishing the
date of birth and/or place of birth.
○ Provide any document, for Mother, from the list given below, establishing the
date of birth and/or place of birth.
○ IfanyparentisnotIndian,provideacopyofhis/hervalidpassport&visaatthe
time of your birth.
● If born outside ofIndia(attachproofofBirthRegistrationissuedbytheIndianMission
abroad),
● If acquired Indian citizenship by Registration/Naturalisation (attach Certificate of
Registration of Citizenship)
Indicative (not exhaustive) list of documents (separate self-attested documents to be
submitted for Self, Father and Mother, if mentioned above):
1. Any Identity card/Pension Payment Order issued to a regular employee/pensioner of
any Central Govt./State Govt./PSU.
2. Any Identity Card/Certificate/Document issued in India by the Government/ local
authorities/Banks/Post Office/LIC/PSUs prior to 01.07.1987.
3. Birth Certificate issued by the competent authority.
4. Passport
5. Matriculation/Educational certificate issued by recognised Boards/universities
6. Permanent Residence certificate issued by the competent State authority
7. Forest Right Certificate
8. OBC/SC/ST or any caste certificate issued by the Competent Authority
9. National Register of Citizens (wherever it exists)
10.Family Register maintained by Govt. officials under any Statute/Administrative
Regulation
11.Any land/house allotment certificate by the Government
12.For Aadhaar, the Commission’s directions issued vide letter No. 23/2025-ERS/[Link]
dated 09.09.2025 (Annexure II) shall apply.
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