ANNEXURE "V" APPLICATION FORM FOR THE GRANT OF DOMICILE CERTIFICATE 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. The year and 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 :- 8. Give details in which made claim to be a domicile in Goa :- (a) Ownership of immovable property in Goa :- Details as such in whose name the property is registered location, value, when brought : (b) Continuous residence in Goa, for the last five years. Details such as deaddress of the applicant since when the applicant has been residing there with whom period of stay at Goa :- (c) Educated or carrying on some Business, trade, etc. in Goa. Details such as name and address of education institution, period of 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 acquired :- 10. Ration Card No. (It should be produced alongwith photostat copy of ration card part 1 and 2 at the time of submission of application form. Signature of Applicant :-______________________ Name of the applicant :-________________________ Address of the applicant :-______________________ Attestation : 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 my personal knowledge. The facts given in the application forms are correct and it has been signed by the applicant for the grant of Domicile Certificate in Goa in my presence. The purpose given by the applicant for the issue of Domicile Certificate is genuine. Signature of attesting authority Name in Block Letters :-_________________ Designation and Address __________________ With Office Seal. NOTE :- The above attestation should be done only on basis of personal knowledge of at least three years by any Under Secretary of Delhi Administration/Government of India, any Magistrate, Superintendent of Police, any Gazetted Officer, holding Class I post of Delhi Administration/Government 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 a part from the Department action.
