Statement as to place of ordinary residence by a member of the Armed Forces

I hereby declare that I am a citizen of India and that but for my service in the Armed Force; I would have been ordinarily resident at— House No ________ Street/MohaUa ________ Locality ________ Town ________ Tehsil ________ District ________ State ________ My full name ________ Service No. ________ Rank ________ Service/Corps/Regiment ________ Name and address of record office ________ Age on last birthday ________ years. I further declare that my wife ________ age ________ years, ordinarily resides with me and is a citizen of India. This cancels any previous statement as ordinary place of residence made by me. Date ____________ 199. Signature __________ Record Office, Verified and found correct. Folio No. ____________ (Signature) ____________ Place ________ (Designation) ____________ Date ____________ Officer-in-charege Records. (For use in the Election Office) Statement received on the ____________ 199. Registered in the electoral roll for the ____________ Constituency (No. ) Service voters' part, at Serial No. ____________ Dated ____________ 199. (Electoral Registration Officer) *Delete if not possible