AFFIDAVIT/SELF DECLARATION

(FOR CHANGE OF DOB OF SPOUSE)

I, SHUBHKALI DEVI (JHA) W/o DURGANAND JHA .presently residing at

201, SHILP AVENUE, Nr VIJAYNAGAR RLY XING,NAVA VADAJ,AHMEDABD-

380013, hereby state the following:

I was born on- 01/01/1954 at VILL-BHAGWANPUR, PO-BHAIYAPATTY

situated in the district-MADHUBANI in the State of - BIHAR.

1- That the date of birth of the deponent is -01/01/1954

2- That the date of birth of the deponent is mentioned in the
Record/PPO as -01/07/1959
3- That the deponent wants to get corrected her date of birth in
Record/PPO as- 01/01/1954 instead of -01-07-1959

I take oath and solemnly declare/affirm that the particulars furnished by me

above are correct and that I have not concealed or misrepresented any facts.
PLACE-
Date.- Signature of Deponent

VERIFICATION
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I, the Deponent above named, do hereby solemnly declare and verify that
the contents of the above Affidavit are true to the best of my knowledge and
belief and nothing has been concealed or suppressed there from.

Signature of Deponent