FORMAT OF APPLICATION FOR INCOME CERTIFICATE

APPLICATION FOR INCOME CERTIFICATEToThe Tehsil / Revenue Officer------------------------------------ Tehsil------------------------------------ DistrictSir,Full Name of the applicant: -----------------------------Name of the Father / Husband / Wife / Guardian: -Age and Date of Birth of the Applicant: -------------Complete address of the Applicant -----------------------------------------Purpose for which income certificate is applied for: ----------Income Details:1. Annual income from Land(s) (appendix-1): ----------------------------2. Annual income from house(s) and shop(s) (appendix-2): ----------------------------3. Annual income on employment: -----------------------------4. Annual income on business: -----------------------------5. Other income (if any): -----------------------------Annual Income From all Sources (add all income 1 to 5 above) : -----------------------------Signature of the ApplicantDeclarationI hereby declare that the details furnished above are true and correct to the best of myknowledge and belief. In the event that any of the details are proved to be false I amliable for punishment under Sec.1999 & 2000 of the Indian Penal Code.Signature of the ApplicantDownloaded from www.lopol.orgIncome Certificate Application Form Page 1 of 5

APPLICATION RECEIPT & NO.(To be received by Applicant)Application Reference No.: -------------------------------------Sri -------------------------------------------- S/o W/oD/o -------------------------------------------- of ---Village has submitted an application for income certificate and is received by this office on---------------- date. The certificate will be issued within 15 days from this day failing whichthe applicant may represent before superior officer in this regard.Signature and designation of the person receiving the applicationDownloaded from www.lopol.orgIncome Certificate Application Form Page 2 of 5

AFFIDAVIT(On Rs. 10/- Non judicial stamp paper or affix Rs. 10/- special adhesive stamp)I --------------------------------------------- S/o Sri d about --------------- years having an occupation of ---------------------------------------,resident of ------------- do hereby solemnly affirmand state on oath as follows:I am the deponent herein as such I am well acquainted with the facts of this affidavit. Isubmit that I am the permanent resident of -------------------------------------- (give complete address) -------- Tehsil -------------------------------- District.I submit that I belong to ------------------------------ Scheduled Caste / Tribe / Backwardclass Group -------------------------------------- at Sl. No. ----------------------------------- whichwas assigned in the Gazette. I submit that I have an annual income of Rs. -------------------from all sources.The said certificate of caste, residence and income is necessary for my son / daughternamed --------.The above facts stated are true and correct to the best of my knowledge and belief. Hencethis affidavit.Sworn and signed before me on this --------------------- day of --------------------------- month----------------- year at (place) s format of affidavit is common for caste, residence & income certificates. Theapplicant needs to declare only the appropriate clauses. In case the application is for all thethree certificates as above only one affidavit including all the three clauses will suffice)Downloaded from www.lopol.orgIncome Certificate Application Form Page 3 of 5

Appendix-11. Details of Lands of the Father / Husband / Wife / GuardianLandsVillageExtentAnnual income1. Land - 12.3.4.5.Total Income From Land(s) - (1)Signature of the Applicant:Name of the Applicant:Date:Downloaded from www.lopol.orgIncome Certificate Application Form Page 4 of 5

Appendix-22. Details of Immovable properties of the Father / Husband / Wife / GuardianDescription ofImmovable PropertiesName of the Local Body(Grampachayat /Municipality / Corpn.)Local BodyWard / Door NoAnnual income1. House -12. Shop -13.4.5.Total Income From Immovable Properties (2)(Tax paid to the Local Body on above house / shop to be shown separately)Signature of the Applicant:Name of the Applicant:Date:Downloaded from www.lopol.orgIncome Certificate Application Form Page 5 of 5

Downloaded from www.lopol.org Income Certificate Application Form Page 5 of 5 Appendix-2 2. Details of Immovable properties of the Father / Husband / Wife / Guardian Description of Immovable Properties Name of the Local Body (Grampachayat / Municipality / Corpn.) Local Body Ward / Door No Annual income 1. House -1 2. Shop -1 3. .