SELF DECLARATION

I,..

W/o

..aged

..,

residing

at.., do hereby solemnly

affirm and declare as under:
1. I am residing at the abovementioned address and have not changed my address
in the past three years.
2. My Aadhar No. is..
3. That my name in my certificates/records is ..
4. That the specimen signature registered in records is ..
5. On registering the new Name in the records, I do hereby covenant and agree
and undertake at all times save, defend and to indemnify and keep indemnified
any part thereof or otherwise in connection with the same, and from and against
all losses, claims, actions, demands, and losses arising in any manner
howsoever.
6. I am executing this declaration to be submitted to the concerned authorities for
the change of my Name in records.

I hereby state that whatever is stated herein above are true to the best of
my knowledge.

Solemnly affirmed at ________

On this ____ day of ______ 2015

(Signature of the Applicant)