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Taluka / Sub - Division Town / City / District State / Union Territory 15. I/We have enclosed proof of address as proof of idenity and I/We what is stated above is true to the best of my/our information and belief. Verified today, the D D M M Y Y Y Y Pin (Indicating PIN is mandatory) as , the applicant, do hereby declare that Signature/ Left Thumb Impression of Applicant (inside the box).

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