Você está na página 1de 1

ANNEXURE -HI

(For Form-6)

DECLARATIONt
(For an elector of 21 + age group seeking fresh registration for the fir.s t
time)
I,. ;;?.~f.l~!.'.~f.l.. · ..-?.~~:.'?.'?.':-: ., Son/Daughter/Wir e of .... 0..~~-'-~.J:!.... Rio ..0.f!J:!J(!(-!_f!_....
.. /-.!J..YfJ.Y.1. .... ...... .... ....... ..... , declare as under: -

I have applied for registration in the electoral roll of .K.


f. .. f:'. ~-0.~ .. constituency,
as my name does not figure in electoral roll anywhere in India.

2. I have not been issued any EPIC at any time in the past in any constituency.
~ --
.,r;::--,
Signatu ~ of the Applicant
Place: !3~r--Jli A t.-o P-- £
Date: 1!? - ~f<.c.i--1 - 2 0 ' '1

*(Making false declaration in matters related to


preparation/revision of electoral roll is an offence
punishable under Section 31 of the Representation of the
People Act, 1951, and also under the provisions of the
Indian Penal Code)

Você também pode gostar