Request Form for Changing the Identity Card [Changing the identity card]

Notary Public

Identity Card Replacement Plan

Number and date of getting the documents: Ordibehesht 20,1366 AHS

Date of turning over: Ordibehesht 23,1366 AHS

Serial number of the bank receipt: A/152 340500

Petitioner: Sayyid Rouhullah Mustafawi

Signature or finger print of the applicant: Rouhullah al-Mousawi al-Khomeini

Full name and signature of the attending officer: `Ali Akbar Rahmani