Part II
APPLICATION FOR THE CORRECTION OF DATE OF BIRTH IN SCHOOL RECORDS
(TO BE FILLED UP AFTER READING THE INSTRUCTIONS)
1. (a) Name (in capital letters) …………………………………………...
1. Name and Address of the Applicant 2. Address …………………………………………………………..……
...……...………………………………………………...........................
District ……………………….………..PINCODE ……………….…
1. Name in block capitals ……..…………………………………………...
2. Details of student whose date of birth
is to be corrected/altered.
2. Relationship with the applicant …………………………………………
3. Place of Birth ……………………………………………………………
4. Panchayat/Municpality/Corporation ……………………………………
5. Name of first school attended ………………………………………......
…….………………………………...……………………………………
6. Standard on admission …………. Date of admission ………………….
7. Completed age at the time of admission .… Year..…....Months…. days
8. Name of school last attended ……………………………………….….
9. Date of leaving the school ………...…………………… Reason for
leaving ……..………………………...………………………………..
10. Educational District …………………………………………………….
11. If belongs to SC/ST state the caste ………………………………….….
(evidence to be enclosed)
Existing date of birth ……………………………Proposed date of birth
3. Nature of correction/alteration
………………………………….. (as per documentary evidence produced)
4. Explanation as to how the incorrect ……………………………………………………………………………..
date of birth happened to be entered
in school records and qualification …………………………………………………………………………….
certificates and how the mistake
came to the notice of the applicant ……………………………………………………………………………
……………………………………………………………………………
……………………………………………………………………………
5. State whether the present application
is within 15 years from the date of Yes/No
leaving the School (Strike out which is not applicable)
2
6. If the answer is ‘No’ state the G.O. (Rt.) No. …………………………. Dated ………..….... (Original to
Government Order condoning be enclosed)
delay
Birth certificate – specify the Registration No.…………………………...
7. Documentary evidence produced to
prove the correct date of birth date ……………….… name of the Panchayat/Municipality/Corporation
……………………………………………………………
Date ………………. Name of Deponent…………………………………...
8. Details of affidavit sworn in
Name of Notary Public/Judicial Officer ……………………………………
Amount ……………… Chalan No………….…….. Date ………………..
9. Details of application fee remitted Name of Treasury ….………………………………………………………
(Applicants belonging to SC/ST need affix only Court fee stamp worth Rs.5/-)
Sl. Date of File No.
Name
No Application (If known)
10. Details of other members in the
family applied for correction of date
of birth
11. Details of birth occurrence in the family (in the order of birth occurrence)
Sl. Date of birth as per Date of birth as per
Name of Child Sex
No. the birth register school records
Place :…………..
Date:…………… Signature of the applicant
3
Declaration of the Applicant
I ………………………………………..…………... (name of applicant) do hereby declare that the details
furnished above are true to the best of my knowledge and belief and I am fully aware and understand that, in case
any information furnished is detected as false in future at any stage, my application will be rejected and I am
liable to be proceeded against in a court of law and such certificate issued on the basis of false information will be
cancelled.
Place :
Date : Signature of applicant
Signature and Name of the parent/guardian
(if the applicant is below 18 years).
OR
b. kX-y-{]-kvXm-h\
…………………………………………………….…… (t]cv) F¶ Rm³ CXn\mÂ
kXy{]kvXmhw \S¯p¶sXs´¶m ta hnhcn¨ hnhc§Ä Fsâ Adnhnepw hnizmk¯nepw
kXyamsW¶pw, Rm³ \ÂInbncn¡p¶ hnhc§Ä GsX¦nepw hymPamsW¶v ]nev¡me¯v GsX¦nepw
Ahkc¯n Is−¯nbmepw AkXyamb hnhc§Ä \ÂInsb¶Xn\v \nba \S]Sn {]Imcw
in£n¡s¸Sm³ ImcWamIpsa¶v F\n¡v ]qÀ®hpw D¯ahpamb t_m²yaps−¶pw A¡mcW¯m P\\
XobXn Xncp¯p¶Xn\pÅ At]£ \nckn¡s¸Sm³ CSbps−¶pw sXämb hnhc§fpsS ASnØm\¯nÂ
P\\ XnbXn Xncp¯s¸«XmsW¦n Xncp¯s¸« kÀ«n^n¡äv d±m¡s¸Spsa¶pw F\n¡v D¯a
t_m²yaps−¶pw {]kvXm-hn-¨p-sIm-Åp-¶p.
Øew :
XobXn : At]£Isâ H¸v
c£nXmhnsâ H¸v
(At]£I³ 18 hbÊv ]qÀ¯oIcn¡m¯ ]£w)
12. Declaration and Recommendation of the Head of School in which the applicant last studied
I hereby declare that the informations furnished by the applicant have been verified by me with reference
to the documents produced by the applicant and the records available in this school and found correct.
I recommend the alteration of the entries for the date of birth of the applicant Shri/Smt. ………………….
………………………………………………….... as requested in the SSLC/TTC.
Place : Signature
Date : Name
Headmaster/Headmistress
……………………………………..
Office seal ……………………………………..
PINCODE
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ANNEXURE I
STATEMENT SHOWING THE PARTICULARS OF EDUCATIONAL INSTITUTIONS
ATTENDED FROM STANDARDS I TO X
Year of Date of admission
Name of School with full postal Standard to Standard
Sl. admission in the School with Year of leaving
address including District which at the time
No. in the admission No. the School
and Pin Code admitted of leaving
School
(1) (2) (3) (4) (6) (7)
Name and Signature of the Applicant.
ANNEXURE II
AFFIDAVIT IN STAMP PAPER
1. For applicants who are 18 years and above (score off if not applicable).
I, …………………………………aged……….son/daughter of Shri……………………….…………..
and Smt. ……………………………………… now residing at ……………………………………………………
……………………………………………………………………………………………...…....(full postal address)
hereby solemnly affirm and declare that my date of birth is ………………………………………………….and
the place of birth is ………………………………………………………………..
My father Shri…………………………………………..has only……………………..child/children born
to him by my mother Smt. …………………………………. including still birth and all the children except
……………………………………… ………………….……....are alive.
OR
For applicants below 18 years (score off if not applicable).
I have only …………… child/children born to me by my wife/husband Smt/Shri ……………..………
………………………. including still birth. All the children except …………………. are alive.
I also declare that the correct date of birth of Master/Kumari ……………………………….…….. is
………………….. and the place of birth is ……………………………………………………….
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2. Names and other details of the children born to the applicant’s family are given below, including still birth.
Sl. Name Male/ Date of Place of Birth Alive or
No. Female Birth not
(1) (2) (3) (4) (5)
The facts given above are true to the best of my knowledge and belief and I am fully aware and
conversant that in case any information furnished is detected as false in future at any stage the application is liable
to be rejected and I am liable to be proceeded against in a court of law for having furnished such false
information.
Dated the ………………….. day of ………………… 201…………….
Place: Signature of the applicant
Date : (To be signed by the father/mother
Signed before me: if the applicant is below 18 years old)
Name, Seal and Signature (To be signed before
of the Notary Public/Judicial Officer. Notary Public/Judicial Officer).
ANNEXURE III
FORM OF IDENTIFICATION CERTIFICATE FROM THE VILLAGE OFFICER
No. …………… (Name and address of Office)
Date …………………
IDENTIFICATION CERTIFICATE
Certified that Shri/Smt. …………………………………..….the (1st/2nd/3rd …..) male/female child born to
Shri…………………………………………………….and Smt. ………………………………………………… of
………………………………………………………………………………………………………………………...
…………………………………………………..(address) on ………………… (D/B) and whose birth registered
at the …………………...……… Panchayat/Municipality/corporation on …..………having Reg. No. .................
is the person Shri/Smt ………………………………………………………………. and the holder of the SSLC
with Reg. No. ………………………..…. of ……………….…………. (Month & Year).
Signature of the Village Officer
Office Seal
Name and Designation.
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9. Conversion Certificate (s) from the State/District Librarian, State Central Library/Dist. Public
Library for all dates in Malayalam era mentioned in any of the documents presented with the
proposal.
The Headmaster on receipt of the proposal shall verify the relevant records at his end. If the case
is bonafide one, he shall submit the application immediately with his detailed report, to the Joint
Commissioner for Government Examinations, Pareeksha Bhavan, Poojappura, Thiruvananthapuram-
695 012. The report should contain the circumstances under which the mistakes occurred.
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•°ª°¬œÞ £°−¸¶½“Ý°µú (RDO) „Ì¥ª¸ ½‰¯¥¹ ¥°èÜ µüÛ¯ª²Ò˜¯—¸.)
1. ¶À‰Ï †−¸.†−¸.†Þ.−° ªµ¥ ”°Å°È²á †ß¯ −¸‰³¨²‰¨°Þ œ°Ò²á ª°«šª°ª¥¹
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¥±À¯¢ªÏ, ³Ô²¥, ˜°¥²ªœÐ²¥¹ - 695 012 †Ò ¶£Þª°§¯−Ì°Þ.
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11
