AFFIDAVIT FOR SELF DECLARATION BY THE POWER OF ATTORNEY HOLDER

Before the Ld. Notary public at????.(Name of place)

D E C L A R A T I O N

I, ______________, W/D/S of _________________, _______(Name of religion) by religion, ____________(Name of Occupation) by Occupation, residing at ______ _____________________________________(Address with pin code, P.O, P.S, District and State) do hereby declare and affirm as follows:-

That I have executed the following works/work order as a Power of Attorney holder of _______________(Name of Power of Attorney holder) vide Power of Attorney executed by ________________( Name of Power of Attorney holder) on dt. ____________(dd/mm/yyyy).

Sl. No.	CA No	Name of Work	Amount

The Statements made above are true to my knowledge and belief and I sign this

Declaration on this the _____ (day) of ________(month), _______(year) at _____________(Name of place).

_________________

D E P O N E N T

Identified by me

Advocate, ______________(Name of place).