I hereby declare that to the best of my knowledge and belief: -
(i) I am a citizen of India;
(ii) I am ordinarily resident at the address given in para II above since (year,month,date)
(iii) I have not applied for the inclusion of my name in the electoral roll for any other constituency;
My name has not already been included in the electoral roll for this or any other assembly constituency;
in which I was ordinarily resident earlier at the address mentioned below and if so, I request that the same may be deleted from that electoral roll.