PROFORMA - I

(This Proforma is intended for the Change of Name only)

Please read the instructions on the reverse *Use one box for one alphabet only
side of this Proforma carefully and fill up the *Leave one box blank after each word
particulars in the BOXES IN ENGLISH *Do not split the word
(BLOCK LETTERS ONLY) *Use next line
From: Thiru / Selvi / Thirumathi

I, (Old Name) My Son / Daughter [For Minor]*

Initial
Son / Daughter / Wife of Thiru

To be Published in the Tamil Nadu Government Gazette.

Born on Date Month Year Age
Male / Female

Native District :

Residing at :
Door No. Old : New :

PIN Code
Number
Shall henceforth be known as (NEW NAME IN BLOCK LETTERS)

(i) Signature.............................................................
Station : (As in the column of Old Name)

Date : (ii) *Signature of Parent or Guardian (if parents deceased) in

the case of minors with relationship in BLOCK LETTERS.

Reason for the Change of Name :...........................................................................................................................................

(i) I hereby declare that I am a native of Tamil Nadu

and residing permanently in Tamil Nadu.
(ii) To prove the nativity, Duly certified copy of the
certificate issued by the Tahsildar (or)
Xerox copy of Ration Card should be enclosed.
(i) Signature...................................................................
(As in the column of Old Name)
(ii) *Signature of Parent or Guardian (if parents deceased) in
the case of minors with relationship in BLOCK LETTERS.

WITNESS
The information furnished above are correct and true to the best of my knowledge and belief.

...................................................................... ......................................................................
Name of the Witness in BLOCK LETTERS Signature of the Witness
Status / Occupation and Address........................................... [The Witness should be an ‘A’ or ‘B’
................................................................................................ Group Officers of Tamil Nadu State (or) Central
Government with seal.]
FOR OFFICE USE ONLY

Mode of Payment Cash / DD For Rs.

R.V. No. : Date : C.P. Register No.
Receipt No. :

R.V. Clerk. Superintendent.

281-4—20,000 Cps.—14-6-08 [P4-13d] [P.T.O.


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Þì«õ‡´‹. M‡íŠðî£ó˜, àKò õòî¬ìò£îõó£è (Minor)
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3. ªðò˜ ñ£Ÿø ÜPM‚¬è îI›ï£†¬ì «ê˜‰îõ˜èÀ‚° ñ†´«ñ.
ÜîŸè£ù àÁFªñ£NJ¬ù àKò ÞìˆF™ ÜO‚è «õ‡´‹.
4. ªðò˜ ñ£ŸøˆFŸè£ù è£óí‹ ªîKM‚è «õ‡´‹.
5. ªðò˜ ñ£Ÿø‚ è†ìí‹: 9-2-2004 ºî™ Ï. 415 ñ†´‹.
6. ªê½ˆ¶‹ º¬ø:
«ïK™ : ðíñ£è
î𣙠Íô‹: àîM Þò‚°ï˜ (ªõOf´èœ)-⿶ªð£¼œ Ü„²ˆ
¶¬ø ݬíòóè‹, ªê¡¬ù-600 002, â¡ø ªðòK™
«îCòñòñ£‚èŠð†ì õƒA õ¬ó«õ£¬ô Íô‹.
7. ðí‹ ªê½ˆ¶‹ «ïó‹:
裬ô: 10.00 ñE ºî™ 1.00 ñE õ¬ó.
HŸðè™: 2.00 ñE ºî™ 3.00 ñE õ¬ó.
(ÜóCù˜ M´º¬ø Fùƒèœ cƒèô£è).
8. ðí M¬ìˆî£œ, Ü…ê™ Ý¬íèœ ãŸèŠðìñ£†ì£¶.
9. M‡íŠðŠ ð®õ‹ Þˆ¶¬øò£™ õöƒèŠð†ì¶ ñ†´«ñ ãŸÁ‚
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10. ðí‹ ªê½ˆ¶õ¶ ªî£ì˜ð£è M‡íŠðî£ó¼‚° G¬ù׆´
㶋 ÜŠðŠðìñ£†ì£¶.
11. M‡íŠðî£ó˜ îMó «õÁ ò£¼ì‹ â‰îMî ªî£ì˜¹‹
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THIS PROFORMA IS INTENDED FOR THE CHANGE OF NAME ONLY
If the change of name is due to the change of religion from one religion to another
a separate PROFORMA-II is available and will be sent on application.
INSTRUCTIONS FOR FILLING THE APPLICATION.
CONDITIONS:
1. Applicant alone should sign in the application (OLD NAME)
In case of minor either parents or guardians (if Parents deceased)
should sign in the column provided.
2. One witness from an ‘A’ or ‘B’ Group Officers of Tamil Nadu State
Government/Notary Public or Central Government, not related to
the applicant should be obtained in the column provided.
3. Notice for change of name will be entertained only in respect of
persons who are native of this State for which they should give
declaration in the column provided.
4. The reason for change of name shall be furnished.
5. Fees: Rs. 415 from 9-2-2004.
6. Method of Payment :
In person : Cash
By Post : Demand Draft in favour of Assistant Director (P),
Commissionerate of Stationery and Printing,
Chennai-600 002, drawn from a Nationalised Bank.
7. Working Hours: For Payment
Morning : 10.00 a.m. to 1.00 p.m.
Afternoon : 2.00 p.m. to 3.00 p.m.
(Except Government Holidays)
8. Money Order/Indian Postal Order are not accepted.
9. The application issued by this Department Alone will be accepted.
Xerox copy will not be accepted.
10. No reminder to the party either for remittance or any other
particulars will be sent.
2
12. M‡íŠðî£ó˜ ºèõKJ™ èî¾ Þô‚è‹ ñŸÁ‹ H¡«è£´
îõø£ñ™ °P‚è «õ‡´‹.
13. Hø‰î ñ£õ†ìˆF¡ ªðò˜ ñ†´«ñ °PŠHì «õ‡´‹.
14. ºîªô¿ˆ¶‚°‹ ªðò¼‚°‹ Þ¬ì«ò ܬñò «õ‡®ò
¹œOèœ êKò£è °PŠHì «õ‡´‹.
15. M‡íŠðî£ó˜ ð¬öò ªðòK™ ¬èªò£ŠðIì «õ‡´‹.
16. «ñ½‹ MõóƒèÀ‚° àîM Þò‚°ï˜ (ªõ), ªê¡¬ù-2 Þ™
2852 0038 â¡ø ªî£¬ô«ðC â‡E™ ªî£ì˜¹ ªè£œ÷¾‹.
17. M‡íŠðî£ó˜ 60 õò¶‚°«ñ™ àœ÷õó£ù£™ ðF¾ ªðŸø
ñ ¼ ˆ ¶ õ K ì I ¼ ‰ ¶ Life Certificate ª ð Ÿ Á Þ ¬ í ‚ è Š ð ì
«õ‡´‹.
ެ특:
I. îI›ï£†®™ Hø‰¶ îI›ï£†®«ô õCŠðõ˜èœ, ެ특 㶋
«î¬õJ™¬ô.
II. Hø ñ£GôˆF™ Hø‰¶ îI›ï£†®™ õCŠðõ˜èœ îI›ï£†®™
õCŠð Ýî£óñ£è àí¾Š ðƒW†´ ܆¬ì/õ£‚è£÷˜
ܬìò£÷ ܆¬ì/õ†ì£†CòKì‹ Þ¼‰¶ ªðøŠð†ì Þ¼ŠHì„
꣡Á, ÞõŸP™ ã«î‹ å¡P¡ ꣡P†ì ïè™ Þ¬í‚èŠðì
«õ‡´‹.
III. ²iè£ó‹ â´ˆ¶‚ ªè£‡´, Üîù£™ ªðò˜ ñ£Ÿø‹ ªêŒ«õ£˜
²iè£ó ðˆFó‹, ðˆFóŠ ðF¾ˆ ¶¬øò£™ ðFòŠð†ì ꣡P†ì
ïè™ Þ¬í‚è «õ‡´‹. «ñ½‹ ²iè£ó‹ ªêŒðõK¡
¬èªò£Šðº‹ ÞìŠðì«õ‡´‹.
IV. Mõ£èóˆ¶ ªêŒ¶ Üîù£™ ªðò˜ ñ£Ÿø‹ ªêŒ«õ£˜ cFñ¡ø
b˜ŠH¡ ꣡P†ì ïè™ Þ¬í‚è «õ‡´‹.
ªðò˜ ñ£Ÿø‹ Hó²óñ£ù ÜóCî› ªðÁ‹ º¬ø:
M‡íŠðî£ó¼‚° Üõó¶ ªðò˜ ñ£Ÿø‹ Hó²óñ£ù ÜóCîN¡
5 ïè™èœ ðF¾ˆ î𣙠Íô‹ ÜŠH ¬õ‚èŠð´‹. ôî™
HóFèœ «î¬õŠð®¡ îQ«ò ðíñ£è«õ£/«è†¹
õ¬ó«õ£¬ôò£è«õ£ ªê½ˆFŠ ªðøô£‹.
11. No correspondence will be entertained with any persons other
than the applicant.
12. Door No. & PIN Code should be written in the address without fail.
13. Specify the Native District only.
14. Specify the punctuations in between Initials and Name accurately.
15. Applicant should sign in old name only.
16. For further details contact Assistant Director (P), Chennai-2 in
Phone No. 2852 0038.
Enclosure:
I. No enclosure is necessary for those who are born in
Tamil Nadu and residing in Tamil Nadu.
II. Those who are born outside the State of Tamil Nadu and
residing in Tamil Nadu duly certified copy of the Ration Card/Voter
Identity/Residential Certificate issued by Tahsildar should be
enclosed.
III. Change of Initial, name due to adoption:
Duly certified Copy of Registered Adoption Deed to be enclosed.
Signature of the Adopted father is necessary in the
application.
IV. Change of name due to divorce:
Duly Certified Copy of Judgement to be enclosed.
Five copies of Tamil Nadu Government Gazette will be sent to the
Applicant in which his name change has been published by Registered
Post. Additional Copies will have to be purchased from the Assistant
Director (P), Commissionerate of Stationery and Printing, 110, Anna
Salai, Chennai-600 002 on payment of cost by means of D.D. or cash.