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Instructions: All details ta be filled in Block Letter (To be valid for 3 months from date of issue)
To be printed on plain AS paper size Not required to print on letter head
Resident's Details
[_JResident [_]Non-Resident indian (NR) [_] New Enrolment [__] Update Request
‘Aadhaar Number:
(Ferupdete only)
Full Name:
co:
House No./ Bldg./ Apt:
Street/ Road/ Lane:
Landmark:
Area/ Locality/ Sector:
Village/ Town/ City:
ome
ene
state seunatee
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fnar
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seunrectenesamy || SSE
Date of Birth: ll | nd
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Name of the Certifier
Designation:
Address:
Contact Number:
Ihereby certify above mentioned details of the resident (Tick appropriate box below)
Gazetted Officer - Group A
village Panchayat Head ar Muihiya
Gazetted officer - Group B
Py MUAY MLC/ Muncipal Counclior
Tensilgar
Head of Recognized Educational institution
‘Superintendent/ Warden) Matron/ Head of Inctitution
‘of Recognized shelter homes/ Orphanages
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Signature ofthe Certfier Stamp ofthe Certifier
NOTE: This fomat is applicable for FOI documents at. Nos. 17,20, 2,22, 31 6 32; PO dacumen at SI. Nos. 23, 24,37, 38,44 6 45; POR documents tS. Nos. 13.
1 DOB documents 3 51 Nos. 5, 14 615 of Schedule Il ofthe Radha (Envelmert ard Updete) Regulation, 2016, 2 avended rom inet time