Organisation : State Election Commission Arunachal Pradesh
Facility : Form 4 to Claim Application for Inclusion of Name
Download Form 4: https://www.electionin.in/uploads/929-form4.pdf
Home Page : http://www.secap.nic.in/index.htm
Related: SECAP Form 5 For Objection to Inclusion of Name : www.electionin.in/932.html
FORM – 4 :
Claim application for inclusion of name.
To,
The Electoral Registration Officer,
Your name should not be included in the electoral roll for any other Constituency or Municipality or Notified Area Authority.
……… Constituency No……
of ……… Gram Panchayat/Anchal Samiti/Zilla Parishad.
Sir,
I request that my name be include in the electoral roll in the above Constituency in part No……relating to Gram Panchayat/Anchal Samiti/Zilla Parishad.
My name in (full)…………………
My father’s/mother’s/husband’s name………………
Particulars of my place of residence are ……………
House No. if any ……………
Village ……………………………
Post Office ………………
Police Station ………………
Block ……… District…………
I hereby declare to the best of my knowledge and belief :-
i) that I am a citizen of India;
ii) that my age on qualifying date, i.e. ……………was ……………..;
iii) that I am ordinarily resident at the address given above ;
iv) that I have not applied for the inclusion of my name in the electoral roll for any other Constituency or Municipality or Notified Area Authority;
v) Or
That my name has been included in the electoral roll in constituency No……………… of Gram Panchayat/Anchal Samiti/Zilla Parishad and I request that the same may be excluded from that electoral roll
Place ……………………… Signature or thumb impression of the claimant.
I am an elector included in the electoral roll of the same part in which the claimant has applied for inclusion, namely Part No………………… of Constituency No…………… of ………………… Gram Panchayat/Anchal Samiti/Zilla Pasrishad. My serial number therein is …………… I support this claim and countersign it.
Signature of the elector
Name (infull)
Note :
Any person who makes a statement or declaration which is false or which he either known or believe to be false or does not believe to be true is punishable under Section 188 of the Arunachal Pradesh Panchayat Act, 1993.
Perforation :
Intimation of Action taken :
The application in Form 4 of Shri/Shrimati/Kumari………………
Address……………………
……………………………
has been ……………
a) accepted and his/her name has been included in the electoral roll vide Sl. No. ………………
Part No…………
b) rejected for the reason ………………
Date :
Electoral Registration Officer
(Address)
Perforation :
Receipt of application :
Received the application in Form No. 4 from Shri/Shrimati/Kumari………… address………………
Date :
Electoral Registration Officer
(Address)