Verification certificate in respect of domicile status of recipient or donor

[To be issued by tehsildar or any other authorised officer for the purpose (required only for the donor - other than near relative or recipient if they do not belong to the state where transplant hospital identified for operation is located)] [See rule 14] Part I (To be filled by applicant donor or recipient separately in triplicate) In reference to application for verification of domicile status for donation o f__________________________(Name of organ/Tissue) from living donor (other than near relative) or recipient under Transplantation of Human Organ Act, 1994 (42 of 1994), submitted on (date)......................................by the applicant donor or recipient, with following details and photograph , along with his or her identification and domicile status for verification Details of Applicant Recipient or Donor Name.................................................... Age....................................................... Sex...................................................... Father or Husband Nam e................ Address: Hospital Reg. No (Recent Photo of Applicant must be signed by him or her across the photo after affixing it) The detail of my donor or recipient are as under and I have enclosed his or her self-signed recent photograph : Name.................................................... Age..................................... Sex..................................... Father or Husband Name Address: Hospital Reg. N o ............................... Signature of Applicant Enclosure : Self signed copy of the donor or recipient for the applicant (to be enclosed ) Part II (To be filled by the certificate issuing authority): The above request has been examined and it is certified that the domicile status of the applicant donor or recipient mentioned as above has been verified as under: Name .............. Son or Daughter or Wife of ............................. resident of village or ward ...............,.................. ,Tehsil or Taluka........................ District................... State or UT ...................... and found correct or incorrect Date........................Place............................. Authorised Signatory Reference No Name and Designation Office Stamp 2. The authorised signatory w ill hand over this verification certificate to the applicant or his or her representative for submission to the Chairperson of the Authorisation Committee of the hospital or district or state (as the case may be), where transplantation has to take place. 3. The authorised signatory shall keep one copy of the above verification certificate for his records and send a copy to the Secretary, Health and Family Welfare of the State Government (Attention Appropriate authority for organ transplant) for information. 4. In case of any suspicion of organ trading, the authorised signatory mentioned above or Appropriate Authority of the state may inform police for making enquiry and taking necessary action as per the Transplantation of Human Organs Act, 1994 (42 of 1994).