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RAJASTHAN GAZETTE

Ordinary

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Published by Authority

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Vol. 77 Asadha 5, Thursday, Saka 1947&June 26, 2025 No. 13

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SPECEIMEN AFFIDAVIT FOR CHANGE IN NAME/DEED POLL/SWORN

AFFIDAVIT

(On non-judicial stamp paper)

By this deed I, the undersigned SAMPATI DEVI (New Name) previously called

SANPATI DEVI (Old name), doing Homemaker (give profession or vocation) and R/o, Wife

of Hukam Chand] Ward No. 13, Station Road, Ranoli Tehsil Dantaramgarh District Sikar

(RAJ.) solemnly declare :-

1. That for and on behalf of myself and my parent and children and remitter issue wholly

renounce/relinquish and abandon the use of my former name of SANPATI DEVI and

in place thereof I do hereby assume from marriage date the name SAMPATI DEVI

and so that I and my parent, children and remitter issue may hereafter be called,

known and distinguished not by my former name, but assumed name of SAMPATI

DEVI.

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 SAMPATI DEVI as my name in place and in substitution of my former name.

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 parent, my

children, remitter issue by such assumed name of SAMPATI DEVI accordingly.

4. In witness whereof I have hereunto subscribed my former and adopted name of

SAMPATI DEVI and affix my signature.

Place : Sikar

Date : 26-05-2025

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Signed and delivered by the above name

Former name" SANPATI DEVI "

New Name" SAMPATI DEVI "

ATTESTED

CHAIN SINGH KHEDAR

26-05-2025

NOTARY PUBLIC

SIKAR-RAJASTHAN.

6376

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