AFFIDAVIT FORMAT

I____________________________________
w/o/d/o_________________________
r/o. __________________________________________ do hereby state on oath:
1. I say that I was born at ______________ and came down to Goa in the year
_______.
2. I say that I am residing at the above address for the last _________years.
3. I say that my name is recorded in the family ration card bearing no.
_____________________ of Village _______________ of
__________Tal!a.
". I say that I have renonced my former domicile from the #tate of my $rigin
i.e.____________.
%. I say that I will ma!e Goa as my &ermanent &lace of residence and frther
state that I have not claimed 'omicile of any other #tate.
(. I say that I am swearing this affidavit in order to &rodce the same before the
)ollector/'istrict *agistrate+ #oth Goa *argao+ inorder to obtain a 'omicile
)ertificate which is re,ired _________________________________.
-. I say that whatever stated above is tre to the best of my !nowledge and
belief and that no &art of it is false.
.lace :
'ate :
'e&onent