1. Name of the Applicant.:- 2. Father's Husband's Name:- 3. Address (a)Permanent. (b) Present. 4. Age5. Type of certificate required: 6. Purpose for which the certificates required. 7. Particulars on the basis of which the certificate is required. 8. List of documents and affidavit ( where necessary) enclosed with the application. 9. DECLARATION. ( Identity / Nativity / Legal heir / Income / Resident / Nationality / Valuation Solvency Possession and any other Certificate) I, Sri /Kumari /Smt. Son daughter wife of SriResident of village P.SOthe District indo hereby declared that the information and particulars stated above are true to the best of my knowledge and belief and they are exhaustive and I have not suppressed any fact. Incase it is detected later on that any of the facts stated above are wrong or that have suppressed some materials. I shall be liable for prosecution under the relevant law . R.I.Office(See.Rule.4) APPLICATION FOR ISSUE OF NATIONALITY CERTIFICATE Place. Signature of the Applicant Date Published on National Portal of India (india.gov.in) Revenue DepartmentGovernment of Orissa
