Delay Birth Affidavit

 

AFFIDAVIT

 

I, _________________ S/o  Sh.______________________________  R/o ____________________________________ do hereby solemnly affirm declare as under;-

1.    That my wife Smt. __________________ W/o   ________________________  R/o _______________________________________ had delivered a Male/Female child namely ________________________________  on ________________________________ at _________________________________________ under the supervision of trained dai namely Smt. ..................... Dai.

2.    That the birth event of said Male/Female child namely __________________________ could not be reported to the concerned PHC/CHC/MC due to some unavoidable circumstances.

3.    That the birth event of said Mae/Female child namely ________________________  was registered in any registration centre in India, earlier.

4.    That is prayed, the birth event of said Male/Female child namely _______________________ was born _________________________ may be registered in the record of PHC/CHC/MC________________________________.

5.    That the deponent has following children and particulars of the other children born to deponent from Smt. __________________ as under:

Name                               Sex                           DOB

                                                                                                        Deponent

Verification

                    Verified that the contents of the above affidavit are true  and correct to the best of my knowledge and belief and nothing has been concealed therein.

Verified at

On_____________                                                                          Deponent