ANNEXURE ‘E’
SPECIMEN AFFIDAVIT FOR CHANGE IN NAME/DEED POLL/SWORN AFFIDAVIT
(On non-judicial stamp paper of minimum value)

 

By this deed I, the undersigned _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (new name) previously called _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (old name), doing _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(give profession or vocation) and resident of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _(address) solemnly declare:

  1. That for and on behalf of myself and my wife, children and remitter issue, I wholly renounce/relinquish and abandon the use of my former name/surname of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ and in place thereof, I do hereby assume from this date the name/surname _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, so that I and my wife, children and remitter issue may hereafter be called, known and distinguished not by my former name/surname, but assumed name/surname of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  2. That for the purpose of evidencing such my determination declare that I shall at all times hereafter in all records, deeds and writings and in all proceedings, dealings and transactions, private as well as upon all occasions whatsoever, use and sign the name of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ as my name/surname in place and in substitution of my former name/surname.
  3. That I expressly authorize and request all persons in general and relatives and friends in particular, at all times hereafter to designate and address me, my wife, my children, and remitter issue by such assumed name/surname of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  4. In witness whereof I have hereunto subscribed my former and adopted name/surname of _ _ _ _ _ _ _ _ _ _ _ _ and _ _ _ _ _ _ _ _ _ affix my signature and seal, if any, this _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ day of _ _ _ _ _ _ _ _ _

Signed sealed and delivered by the above name
Date_ _ _ _ _ _ _ _ _ _ Former name _ _ _ _ _ _ _ _ _ _ _ _ _
In the presence of:
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Name _ _ _ _ _ _ _ _ _ _ _ _
Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ Address _ _ _ _ _ _ _ _ _ _ _

(This deed poll/affidavit may be signed and attested in presence of a Magistrate/Notary or Consular Officer in an Indian Mission abroad)

Note: In case of change of name, applicant should insert advertisements in two reputed newspapers (one local newspaper of the area in which he/she is residing and 2nd in newspaper of the area of permanent address) and submit original newspapers at the time of applying for passport in his/her new name.