Annexure C
Enumeration Form
Elector's Name, EPIC, Address (Pre-printed).
Serial No, Part No. & name, AC/PC Name, State (Pre-printed).
Old Photo Paste Current
(Pre-printed) Photo
Date of Birth AADHAAR No. (Optional) Mobile No.
Father's/Legal Guardian Name EPIC No. (if available)
Mother's Name EPIC No. (if available)
Spouse's Name (if applicable) EPIC No. (if available)
DECLARATION
I HEREBY DECLARE that to the best of my knowledge and belief-
(i) I am above 18 years of age, ordinary resident on the above address and a
citizen of India, and (tick any one)
I was born in India before 01.07.1987
• Provide any document, for Self, from the list given below
establishing date of birth and/or place of birth.
I was born in India between 01.07.1987 and 02.12.2004
Provide any document, for Self, from the list given below
establishing date of birth and/or place of birth.
Provide any document, for Father or Mother, from the list given
below establishing date of birth and/or place of birth.
I was born in India after 02.12.2004
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Provide any document, for Self, from the list given below
establishing date of birth and/or place of birth.
Provide any document, for Father, from the list given below
establishing date of birth and/or place of birth.
Provide any document, for Mother, from the list given below
establishing date of birth and/or place of birth.
If any parent is not Indian, provide a copy of his/her valid passport
& visa at the time of your birth.
I wasborn outside of India (attach proof of Birth Registration issued by
Indian Mission abroad),
I have acquired by Registration/Naturalisation (attach
Indian citizenship
Certificate of Registration of Citizenship)
(ii) I have not acquired the citizenship of any other country.
(iii) applying for inclusion in the Electoral Roll and my name is not included
I am
in any other Assembly Constituency/ Parliamentary Constituency.
(iv) I am aware that making the above statement or declaration in relation to
this application which is false and which I 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.
Date: Place: Signature/Left Thumb Impression
Indicative (not exhaustive) list of documents to be submitted in support
of the declaration (separate self attested documents to be submitted for
Self, Father and Mother, if mentioned above, except where extract of the
Electoral Roll of Bihar with qualifying date 01.01.2003 is used, which will
be considered as a sufficient document in itself):
1. Any Identity card/Pension Payment Order issued to regular
employee/pensioner of any Central Govt./State Govt./PSU.
2. Any Identity Card/Certificate/Document issued in India by 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 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, prepared by State/Local authorities.
11. Any land/house allotment certificate by Government
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Annexure D
Declaration Form
(To be submitted alongwith Form 6/8 for enrolment as a new Elector/shifting
from outside the state)
I HEREBY DECLARE that to the best of my knowledge and belief-
(i) I am above 18 years of age, ordinary resident on the above address, and
citizen of India, and (tick any one)
I was born in India before 01.07.1987
Provide any document, for Self, from the list given below
establishing date of birth and/or place of birth.
I was born in India between 01.07.1987 and 02.12.2004
Provide any document, for Self, from the list given below
establishing date of birth and/or place of birth.
•
Provide any document, for Father or Mother, from the list given
below establishing date of birth and/or place of birth.
I was born in India after 02.12.2004
Provide any document, for Self, from the list given below
establishing date of birth and/or place of birth.
Provide any document, for Father, from the list given below
establishing date of birth and/or place of birth.
•
Provide any document, for Mother, from the list given below
establishing date of birth and/or place of birth.
If any parent is not Indian, provide a copy of his/her valid passport
& visa at the time of your birth.
I was born outside of India (attach proof of Birth Registration issued by
Indian Mission abroad),
Π have acquired Indian citizenship by Registration/Naturalisation (attach
Certificate of Registration of Citizenship)
(ii) I have not acquired the citizenship of any other country.
(iii) I am applying for inclusion in the Electoral Roll and my name is not included
in any other Assembly Constituency/ Parliamentary Constituency.
(iv) I am aware that making the above statement or declaration in relation to
this application which is false and which I 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.
Date: Place: Signature/Left Thumb Impression
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Indicative (not exhaustive) list of documents to be submitted in support
of the declaration (separate self attested documents to be submitted for
Self, Father and Mother, if mentioned above, except where extract of the
Electoral Roll of Bihar with qualifying date 01.01.2003 is used, which will
be considered as a sufficient document in itself):
1. Any Identity card/Pension Payment Order issued to regular
employee/pensioner of any Central Govt./State Govt./PSU.
2. Any Identity Card/Certificate/Document issued in India by
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 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, prepared by State/Local authorities.
11. Any land/house allotment certificate by Government
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