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Form – E
[ See Rule 7 (3) ]
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Second Appeal under Section 19 (3) of the Act
From
………………………………….
(Applicant’s Name & Address)
Before
The State Information Commission
- Full Name of the Appellant :
- Address :
- Particulars of the first Appellate Authority :
- Date of receipt of the order appealed against :
- Last date for filing the appeal :
- Particulars of information
- Nature and subject matter of the information :
required
- Name of the officer or Department to which :
the information relates
- The grounds for appeal :
(Details if any to be enclosed in separate sheet)
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Verification
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| I, ……………………………………………………………. Name of the appellant, son of / daughter of / wife of …………………………………………………… hereby declare that the particulars 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. |
| Place : |
Signature of the Appellant
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| Date : |
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To
……………………………………………..
Orissa State Information Commission |
