From:
Name: ______________________________
Address: _____________________________
_____________________________.
Dated: / /200 .
To,
The Collector/District Magistrate,
South Goa District, Margao Goa.
APPLICATION FORM FOR THE GRANT OF DOMICILE CERTIFICATE
Facts
1. Name ( in block letters) __________________________________________________
2. Address of the applicant __________________________________________________
3. Date and place of Birth __________________________________________________
4. Name of father/ Husband _________________________________________________
5. Address of father, if living otherwise,
last address____________________________________________________________
6.Time year & date from he/she is residing in Goa continuously
____________________________________________________________________
7. Have you obtained domicile certificate of any place other than Goa.
If any. Give reasons for applying domicile certificate in Goa.
In details : __________________________________________________________
8. Give details in which made claim to be a Domicile in Goa.
(a) Ownership of movable property in Goa.
Details as such in whose name the property is registered
_______________________ location ___________________ value _____________
when bought _______________________________.
(b) Continuous residence in Goa for the last five years.
Details such as do address of the applicant ________________________________
________________ since when the applicant has been residing there____________ ____________________ with whom ______________________ period of stay at Goa ___________________________________.
(c) Education or carrying on business, trade etc. in Goa.
Details such as name and address _______________________________________
R/o _______________________________________ Study there etc. ____________
_____________________________________ place of business, ________________
period ____________ whether he/she is owner of firm/partner of firm etc ___________________________________________________________________.
9. For what purpose the domicile certificate is required
_______________________________________________________________________ .
10. Ration Card No. _______________________________ at Sr. No. _______ issued by Mamlatdar of ______________________________ ( it should be produced alongwith Photostat copy of ration card part 1 & 2 at the time of submission of application form)
Signature of applicant________________________
Name in Block letter ________________________
DECLARATION TO BE SIGNED BY THE APPLICANT
1. That all the facts are correct and nothing has been cancelled.
2. That I do not claim domicile Certificate of any other place other than Goa.
3. That I have not applied or obtained certificate of domicile from some other State.
4. That I intend to make Goa, as permanent place or residence.
Signature of applicant _______________________
Name in Block letters ________________________
Residential address __________________________
_________________________________________.
DECLARATION TO BE SIGNED BY THE GUARDIAN IF APPLICANT IS MINOR
1. That all facts given are correct and nothing has been cancelled.
2. That any word has not claimed domicile and other place other than Goa.
3. That any work intend to make Goa as permanent place or residence.
Signature of Guardian _______________________
Name in Block letters ________________________
Residential Address _________________________
_________________________________________
Note: Minor will take the Domicile of their parents, married upon that of her husband, student wholly dependent and adult may accept the domicile of one when he/she is fully and entirely dependent.
Attestations:
Shri/Smt/Kum ______________________________________________ s/o,w/o,D/o
___________________________________ resident of _________________________________
____________________________________ is personally known to me for the last __________ ________________ years . I have attested the form of applicant for grant of domicile certificate on any personal knowledge. The facts given in the application form are correct and it has been signed by the applicant for the grant of domicile certificate in Goa, Daman and Diu in any presence. The purpose given by the applicant for the issue of domicile certificate is genuine,
Signature of the attested authority__________________
Name in Block letters ___________________________
Designation and Address_________________________
With office seal
NOTE:
The above attestation should be done only on the basis of personal knowledge of at least three years by any Under Secretary of both Administration/Govt of India, any Magistrate, Superintendent of Police, any Gazetted Officer holding Class I post of Delhi Administration/Govt. of India.
WARNING
In case Attesting Officer make false attestation either willfully or due to insufficient information in verifying the facts cited in the application, he will be liable to Criminal proceedings, under the Indian Penal Code apart from the Departmental action.
-----------------------
No:________________________ Dated: / / 200
To,
The Collector/District Magistrate, South Goa District, Margao.
Sir,
The attestation of the application of Shri/Smt/Kum. _____________________________________ S/o.D/o.W/o. _____________________________ resident of ________________________________________ has been done by me on the basis of personal knowledge of (a) the ownership of innovably property in Goa(b) Continuous residence of Goa for the last ________________________ years, or (c) the facts that the applicant has been educated/carrying sore business/occupation trade in Goa. (Please give details)
________________________________________________________________________
Further to above, I state that I am holding Class-I GAZETTED POST /MAGISTRATE POST
Signature of Attesting Authority
Full Name ___________________________
Office Seal with Complete address ___________________________________________
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 __________Taluka.
4. I say that I have renounced my former domicile from the State of my Origin i.e.____________.
5. I say that I will make Goa as my permanent place of residence and further state that I have not claimed Domicile of any other State.
6. I say that I am swearing this affidavit in order to produce the same before the Collector/District Magistrate, South Goa Margao, inorder to obtain a Domicile Certificate which is required _________________________________.
7. I say that whatever stated above is true to the best of my knowledge and belief and that no part of it is false.
Place :
Date :
Deponent