S.No. PROFORMA - I

1 PROFORMA - I(This PROFORMA is intended for the Change of Name only) SELF ATTESTATIONThe information furnished above are correct and true to the best of my knowledge and of the Applicant with name in BLOCK LETTERSFOR OFFICE USE ONLYMode of Payment Cash / DD For No.:Date Register No.: [ 281-8 29-05-2015 [Lenove-3]Please read the instructions on the reverseside of this PROFORMA carefully and fill upthe particulars in the BOXES IN ENGLISH(BLOCK LETTERS ONLY)*Use on one box for one alphabet*Leave one box blank after each word*Do not split the word*Use next lineTo be Published in the Tamil Nadu Government : Thiru / Selvi / ThirumathiI,(OldName) MySon/ Daughter[ForMinor]*InitialSon/ Daughter/ Wife of ThiruBorn on Date Month YearSex Age Male/ FemaleDistrict of Birth:Residing at:Door :New.]

2 PIN CodeNumberShall henceforth be known as (NEW NAME IN BLOCK LETTERS)Gazette to be got inperson by post(i) : (As in the column of Old Name)Date :(ii) *Signature of Parent or Guardian (if parents deceased) inCELL No. /Phone No. the case of minorswithrelationship inBLOCK Number: 1000 No. & Date:(i)I hereby declare that I am a native of Tamil Naduand residing permanently in Tamil Nadu.(ii)To prove the nativity, Duly certified copy of the(i) issued by the Tahsildar (or)(As in the column of Old Name)Xerox copy of Ration Card should be enclosed.(iii)I hereby declare that I shall be held responsible for any(ii)*Signature of Parent or Guardian (if parents deceased) inmisinformations funished by case of minors with relationship in BLOCK for the Change of Name.

3 [Proof of Old Name: Birth Certificate/School TC Must beenclosed][Xerox copy of Ration Card/ Voter ID/ Passport /Driving Licence should be enclosed][PIN Code must be Written, without Pincode form will be returned]In case ofMinor, a recentPassport sizephoto of theParent/Guardianshould beaffixed withdue selfattestationAffix arecentPassportSize Photowith dueselfattestationFor Change of Nameof Minor Only2 F -22222- M H .G :G :G :G :G :1. M F M . M 18 F (Minor).

4 H G I (Legal GuardianshipOrder) . F W M (Capital Letter- ) / / P H .2. O . O . O . O . O .3. PM I I I I I .. F NJ K F O .4.

5 F KM .5. : 9-2-2004 .415/- 415/- 415/- 415/- 415/- .6. : : : : : K : K : K : K : K : : : : : : M ( Of ) , -600 002, K Y A .7. : : : : : : E E H : E E ( M F c ).8. M ( ) ..9. M G .10. M ( ) FM.

6 11. M M M .12. M KJ K H H H H H P .13. H F F F F F P H .14. O O O O O K P H .15. M K K K K K I .16. M 60 F K I Life Certificate .17. M M ( ), -2 2852 0038, 2854 4412 28544413, 28544414 C E.

7 18. ( ) F K , A (Alias) H K . C N H H C N H H C N H H C N H H C N H I H F K I H F K I H F K I H F K I H F K .. H H F M K .20. H / M P F G H K K P H .21. e F M K , O F.

8 22. C K M KM , C H K 5 K C . P C K .23. C , F F , C , K e . G O , K 6 K , F , C .24. i F , i ( ) , M H , F K F . :I. I H I C H P / M P / F P.

9 I M F W / / Y P P P .II. H G F H , I C I C H P / W / / C K H , P P P .III. i , W H .1. i / H i F i F L , H P .2. i / O i / P H Of PM OJ.

10 ( ) F i F L , H P , .IV. M cF b H L I I I I I . / H C :H C :H C :H C :H C :M / M / M / M / M / H C N 5 F H C N 5 F H C N 5 F H C N 5 F H C N 5 F H.