Hand Book for Gaon Burahs and Panchayati Raj Leader

83ANNEXURE (A)IN THE COURT OF EXECUTIVE/JUDICIAL MAGISTRATE I/II nd CLASS: -JUD/NO…………DATE………AFFIDAVITI Shri/Smti/Miss……………………….aged……years Son/Daughter/Wife/Elder/Sister of ………... By religion:……….by Nationality:…………byoccupation:…………...,permanent resident of village…….P.O……………P.S……….. Dist………..State……Ph. no…….Presently residing at (name ofvill/town)……………..P.O…………….P.S………………Dist. (A.P.), Ph.no…………… do hereby solemnly affirm and declare as follows:01. That I am the (relation with whom the case is applied for) and Naturalguardian of ……………………..and the name of her/his mother (in caseof father is deponent) is ………………………and vice versa.02. That my aforesaid child/person (name)………………was born/died on(date to be mentioned)…………………..at …………………………(placeof occurrence).03. The name of his/her father is …………………………………….andmother is…………………(in case deponent is other than father andmother).04. That till date I have neither registered the name of aforesaid child, beforeDistrict Registrar Birth and Death, before any registrar in India, norobtained birth certificate for aforesaid event from any registrar of birthand death, which is required under RBD, ACT-1969 due to………………………………………(write reason for late report)05. That my aforesaid child is a school going student/not going and readingin class………….standard.06. That this deed of affidavit is sworn in to obtain birth/ death certificatefrom the competent authority for…………………….(purpose for whichthe certificate is sought).That the contents of para 01to 06 above are true and correct from mypersonal knowledge and belief. If any information as furnished above is foundfalse at any time, then I shall be liable to be punished as per relevant law.DECLARATION OF WITNESS:The contents of para 01 to 04 as furnished by the deponent above aretrue and correct from my personal knowledge and belief. If any falseinformation arises in any point of time, then I shall be liable to be punished asper the relevant law.1) Witness :- 2). Witness :-Name and signature Name and signatureSolemnly affirmed and declared by the both deponent & the witnessesbefore me on……. at…………… . The deponent & witness have understood