I, , D.O.B.- , , by faith- , by occupation- , residing at Vill.- , P.O.- , P.S.- , Dist.- , Pin- , , do hereby solemnly affirm and declare as follows :-
| 1. | That I am a citizen of India and have been residing at the above noted address permanently. |
| 2. | That I was born on , Vill.- , P.O.- , P.S.- , Dist.- , Pin- , . |
| 3. | That I have no birth Certificate to show my place and date of birth. |
| 4. | That I do not possess any educational qualification and I am an illiterate person. But I can sign my name in my own efforts. |
| 5. | That I swear this affidavit for the purpose of avoiding future complication regarding my place and date of birth. |
That the above statements made by me are true to the best of my knowledge & belief and if any information and documents are found false, I shall be punishable u/s 229 of B.N.S.