Election Commission of India

APPLICATION FOR RECTIFICATION OF DEFECTS IN ELECTORS PHOTOIDENTITY CARD (EPIC)

FORM ID ECI-EPIC-004

PART A : Electors Details ( To be filled by the Elector) To Sir/Madam, The Electoral Registration Officer, I am/was an elector of the constituency mentioned ..Constituency. below and I was issued with Electors Photo Identity Card. Particulars in this regard are given below : 1. First & Middle Name 2. Last Name 3. EPIC No. of Original Card I. Applicants Details 4. Assembly constituency (PC@ ) No. & Name: 5. Part No. of Electoral Roll: 6. Sl. No. in that Part: II. My correct particulars are given below : Item Particulars to be shown in EPIC Name a) b) *Fathers/Mothers/Husbands name d) Age e) Date of Birth c) Sex f) Address
(i) House/Door Number (ii) Street/Mohalla/Road/Galli (iii)Area/Locality (iv)Town/Village (v) Police Station (vi)District (vii)Pin Code

I submit that: (Tick P the appropriate box ) A. Required corrections in my EPIC may be carried out as per particulars given above. B. I have been issued EPIC, but wrong photograph has been affixed and this may be changed. C. In the current Electoral Roll, EPIC number is indicated against the entries relating to my name. However, I have never been photographed so far. Arrangements may be made to photograph me and to issue the Card to me. D. In the current Electoral Roll, EPIC number is indicated against the entries relating to my name. However, I have not received EPIC so far. Arrangements may be made to issue the Card to me. E. I was photographed earlier but EPIC was not issued to me. The same may be issued. F. I was issued with EPIC. However, my name is not included in the current Electoral Roll. I have separately applied for inclusion of my name in Form-6 which is enclosed. G. The Serial Number of the EPIC issued to me has been wrongly printed in the Electoral Roll. The Roll may be corrected to show the correct number of the EPIC issued to me. H. I was issued with EPIC, but serial number of the said EPIC is not printed in the Electoral Roll. This may be included in the Roll.

Date:

Signature or Thumb impression of the Elector

@ PC number incase of Union Territories not having Legislative Assemblies * Strike out the inappropriate alternative

PART B: Details of Action Taken (To be filled by EROs Representative) AC (NO.& NAME): DISTRICT:
Designated Photographic Location (DPL) No: Register No. Field Unit No Serial No. In Register

CAMPAIGN ID: WB-2000-01

Receipt Number

The application of *Shri / *Smt / *Km .. for rectification of defects in the Electors Photo Identity Card in Form ECI-EPIC-004 has been disposed of and action taken as per details given below

(Tick 4 appropriate box when complete)

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The error(s) relating to the particulars of the Elector in Electors Photo Identity Card have been corrected as per correct particulars given in Part A of this form and : New card issued as per details below Sticker issued Wrong Photograph$ has been replaced as per details below. EPIC Number was shown in Electoral Roll, but elector was neither photographed nor issued EPIC $ . Hence, EPIC is replaced as per details below.

o o

The elector was photographed earlier but EPIC was not issued and the undistributed EPIC is now issued as per details below#

On Application in Form6, the name of the elector (already issued with EPIC) has been included in the Electoral Roll as per details below# :

EPIC Serial Number was wrongly printed in the Electoral Roll and this has now been corrected as per details below. #

EPIC Serial Number was not printed in the Electoral Roll a nd this has now been included as per details below. #

EPIC Details (As updated) (a) EPIC Number (b) Image File Number

(c) Part No. (e) Date of Photography Personal ID No.(PIN) of EROs Rep

(d) Serial No. (f) Date of issue of EPIC/ Sticker Authorised Issue of EPIC/Sticker

Signature & Seal of EROs Representative

* Strike out inappropriate alternative. $ New Photograph has to be taken and linked and a replacement Card is to be issued. # Indicate Card No./ Part No./ Serial No.