Annexure C Enumeration Form Elector's Name, EPIC, Address (Pre-printed), Serial No, Part No. & name, ACIPC Name, State (Pre-printed). Old Photo Paste Current (Pre-printed) Photo Date of Birth AADHAAR No. (Optional) Mobile No. Father's/Legal Guardian Name EPIC No. (if available) Mother's Name EPIC No, (if available) Spouse's Name (if applicable) EPIC No. (if available) DECLARATION | HEREBY DECLARE that to the best of my knowledge and belict- (@) 1 am above 18 years of age, ordinary resident on the above address and a citizen of India, and (tick any one) GI was born in india before 01.07.1987 * Provide any document, for Self, from the list given below establishing date of birth and/or place of birth, © Iwas born in India between 01.07.1987 and 02.12.2004 * Provide any document, for Self, from the list given below establishing date of birth and/or place of birth * Provide any document, for Father or Mother, from the list given below establishing date of birth andior place of birth. C0 Iwas born in India after 02.12.2004 Page 16 of 19* Provide any document, for Self, from the list given below establishing date of bith andlor place of birth * Provide any document, for Father, from the list given below establishing date of bith andlor place of birth ‘+ Provide any document, for Mother, from the list given below ‘establishing date of birth and/or place of birth. ‘If any parent is not indian, provide a copy of his/her valid passport & visa at the time of your birth. © | was born outside of India (attach proof of Birth Registration issued by Indian Mission abroad), © I have acquired indian citizenship by Registration/Naturalisation (attach Certificate of Registration of Citizenship) (i) Ihave not acquired the citizenship of any other country. (ii) Lam applying for inclusion in the Electoral Roll and my name is not included in any other Assembly Constituency/ Parliamentary Constituency. (v) 1am aware that making the above statement or declaration in relation to this application which is false and which | know or believe to be false or do not believe to be true, is punishable under Section 31 of Representation of the People Act,1950 (43 of 1950) with imprisonment for a term which may extend to one year or with fine or with both. Date: Place: Signature/Left Thumb Impression Indicative (not exhaustive) list of documents to be submitted in support of the declaration (separate self attested documents to be submitted for Self, Father and Mother, if mentioned above, except where extract of the Electoral Roll of Bihar with qualifying date 01.01.2003 is used, which will be considered as a sufficient document in itself): 1 Any Identity card/Pension Payment Order issued to regular employee/pensioner of any Central Govt,/State Gov/PSU. 2. Any Identity Card/Certificate/Document issued in India by Government! local authorities/Banks/Post OfficelLICIPSUs prior to 01.07.1987. 3. Birth Certificate issued by the competent authority. Passport Matriculation/Educational certificate issued by recognised Boards/universities Permanent Residence certificate issued by competent State authority Forest Right Certificate OBCISCIST or any caste certificate issued by the Competent authority National Register of Citizens (wherever it exists) 10, Family Register, prepared by State/Local authorities. 11. Any land/house allotment certificate by Government Page 17 of 19 oe exe