FOR% [See rules 13(3) and 26]

Application for correction to particulars entered in electoral roll

To The Electoral Registration Officer, .......................................................... sse!"l#$ % &arlia!entar# 'onstituenc#.
SPACE FOR PASTING ONE RECENT PASSPORT SIZE P OTOGRAP !"#$ C% & "#$ C%'S O(ING FRONTA) *IE( OF F+)) FACE (IT IN T IS ,O&

Sir, ( re)uest that entr# relating to !#self a**earing in the electoral roll for the a"o+e 'onstituenc# is not correct and it should "e corrected. 'orrect *articulars in su**ort of !# re)uest are gi+en "elo, I# Applicant.s .a!e () Surna!e (if an#) {()}
/etails
(/loc0 'a*ital 1etters)

&art nu!"er of electoral rollge as on 1st 2anuar#............. 3 8ate of "irth, if 0no,n 9 7ather:s$ 5other:s $ .a!e ;us"and:s

4ears8a# -

Serial nu!"er in that *art 5onthsSe6 (5ale$7e!ale)5onth 4ear .a!e () Surna!e (if an#)
{()}

(/1O'< ' &(T 1 1ETTERS)

Particulars of place of or/inar0 resi/ence !Full a//ress'1 ( ) ;ouse2 8oor .o. ( ) 1

II# To,n $ =illage ( /) : &ost Office ( ) :

Street$ rea$1ocalit#$5ohalla$Road (///) :

&in 'ode ( )
8istrict ( ):

Tehsil$Talu0a$5andal$Thana () :

III# 3etails of Electors. Photo I/entit0 Car/ !if issue/4 in this or some other constituenc0' Electors: *hoto identit# card nu!"er .a!e of the constituenc# I*#3etails of entries to be correcte/ 1 95# na!e $ 9 ge $ 97ather:s $ 5other:s $ ;us"and:s na!e $ 9Se6 $ 9 ddress $ 9Electors: *hoto identit# card nu!"er !a# "e corrected in ter!s of infor!ation *ro+ided in this 7or! a"o+e. &lace 8ate Signature or thumb impression of the elector

Note 1 An0 person 5ho ma6es a statement or /eclaration 5hich is false an/ 5hich he either 6no5s or belie7es to be false or /oes not belie7e to be true4 is punishable un/er section "8 of the Representation of the People Act4 89$: !;" of 89$:'# % (n case of >nion territories ha+ing no 1egislati+e sse!"l# and the State of 2a!!u ? <as!ir 3 &lease gi+e the #ear i.e. 2@@3, 2@@A, etc. 9 Stri0e out the ina**ro*riate alternati+e

3etails of action ta6en (To be fille/ b0 Electoral Registration Officer of the constituenc0)
The a**lication of Shri$S!t.$<!........................................................................BBBBBBBBfor correction of entr# in the electoral roll in 7or! C has "een acce*ted9$ reDected9. 8etailed reasons for 9acce*tance [under or in *ursuance of rule 1C9$2@9$26(A)%] or 9reDection [under or in *ursuance of rule 1E9$2@9$26(A)%]-

&lace 8ate -

Signature of Electoral Registration Officer

(Seal of the Electoral Registration Officer)

9 Stri0e out the ina**ro*riate alternati+e % 8uring continuous u*dating after final *u"lication of electoral roll.
Remar6s of Fiel/ )e7el Officers !e#g ,)O4 3esignate/ Officer4 Super7isor0 Officer'

[7OR5 C 'ontdB..]

<This page shoul/ be thic6 enough so that it /oes not get mutilate/ 2 /amage/ in postal transit=
Intimation of action ta6en !Section>II of the page is to be fille/ in b0 Electoral Registration Officer of the constituenc0 an/ to be poste/ to the applicant on the a//ress as gi7en b0 the applicant in Section>I'

BBBBBBBBBBBBB..BBBB.7irst 7oldBBBBBBBBBBBBBBBB.BB...B SectionF(

&ostage Sta!* to "e affi6ed "# the Electoral Registration uthorit# at the ti!e of dis*atch

The a**lication in 7or!FC of 99Shri$Shri!ati$<u!ariBBB.. 99 (7ull ddress)

;ouse$8oor nu!"erStreet$ rea$1ocalit#$ 5ohalla$RoadTo,n$=illage&ost Office&in 'odeTehsil$Talu0a$ 5andal$Thana8istrict99 To "e filled in "# the a**licant. BBBBBBBBBBBBBBBBBB.Second 7oldBBBBBBBBBB..BBBB...BB.. SectionF(( has "eenFFFF (a) acce*ted and the na!e of Shri$Shri!ati$<u!ariBBBBBBBBBBBBBBBB..has "een at Serial .o. BB.. in &art .o. BBBB of ' .o.? .a!e ..BBBBBBBBBBBBBBB.. (") reDected for the reason BBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 8ateBBBBBBB. Electoral Registration Officer ( ddress) BBBBBBBB. BBBBBBBBBBBB.. BBBBBBBBBBBB..

BBBBBBBBBBBBBBBB.&erforation for detach!ent BBBBBBB.BBBBBB..

Receipt for application Recei+ed the a**lication in 7or! C of 99 Shri$Shri!ati$<u!ariBBBBBBBBBBBBBB.. 99 ddressBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 8ateBBBBB Signature of the officer recei+ing the a**lication on "ehalf of the Electoral Registration Officer ( ddress). BBBBBBBBBBBBBBB.

99 To "e filled in "# the a**licant.