APPLY FOR SECOND APPEAL: ORISSA INFORMATION COMMISSION


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FORM-E
[See Rule 7(3)]
Second Appeal under Section 19 (3) of the Act

From

Applicant's Name

Address

	State
	District

The Orissa Information Commission.

*1.

Full Name of the Appellant :

*2.

Address :

*	(a)	State :
*	(b)	District :
	(c)	City/Town/Village :
	(d)	E-Mail ID :

*3.

Paticulars of the First Appellate Authority :

*4.

Date of Receipt of the order
appealed against :

(Attach soft copy if required).

(.pdf,.jpg,.gif file only)

*5.

Last date for filing the appeal :

Particulars of Information

(a) Nature of the subject matter of the information required :

*	(b)	Name of the Department to which the information relates
	*	Name of the Office to which the information relates

The grounds for appeal :

Signature of the Appellant :

(.jpg,.gif,.png,.bmp file only)

Supporting Documents

Document Name	Date	Upload Soft Copy

Copy of Form A *

Copy of Receipt in Support of payment of fees for Submission of Form A application*

Copy of self-attested copies of the orders or documents against which the appeal is preferred*

Copies of documents relied upon by the appellant and referred to in the appeal is preferred*

Copy of an index of the document referred to in the appeal*

Copy of Self- addressed duly stamped envelope for intimation of defects in case the memorandum of appeal is sent by registered post*

Copy of Self attested copy of Form “D” application (if any). Copy of receipt in support of payment of fees for filing of Form “D” application

VERIFICATION

(Name of the appellant) of

hereby declare that paticulars furnished in the appeal are to the best of my Knowledge and belief, true and correct and that I have not suppressed any material fact.

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NOTE :- (*) marked fields are mandatory.Please upload images maximum size (250*50) and document upto (1 MB).