APPLICATION FORM FOR INCOME CERTIFICATE 1. Name of applicant (Parent) : 2. Son / Wife of : 3. Address A) Permanent Address : Village : Post Office : Police station : Circle : District / State : B) Present address : Village : Post Office : Police station : Circle : District / State : 4. Age : 5. Sex : 6. Occupation : 7. Nationality : 8. Place of domicile : 9. Religion : 10. For whom certificate needed and relationship with him / her : 11. Purpose for which certificate is needed : 12. Annual income for the year 2000 from all sources : 13. Sources of Income : 14. Whether such certificate was obtained : previously, if yes what happened to earlier certificate? State reason for applying again DECLARATION OF THE APPLICANT I solemnly declare that I am not a government employee and my wife / husband is also not a government employee. I shall be liable to be prosecuted for any false statement, concealment of fact etc. SIGNATURE OF APPLICANT (PARENT) Name:............. Date:.......... DECLARATION OF VERIFYING OFFICER I have personally verified the House Hold Survey record of the year ...... of my block and as per the record the annual income of Shri/ Smti .. .... .... .. is Rs. .. ... (Rupees .. .. .. .. .. .. .. ) only. Also certified that the applicant or his wife / husband is not employed in any Govt. service. I shall be responsible for any false verification. Signature of the Block Development Officer Name :........... Date :..........
