Scribd
Upload
54 views1 page

Self Declaration Income

This document is a self-declaration form where the applicant affirms the truthfulness of the information provided regarding their personal details and family income sources. The applicant acknowledges their responsibility for the accuracy of the declaration and the consequences of providing false information under Indian law. The form also includes sections for detailing various sources of family income and requires the applicant's signature, date, and place of declaration.

Uploaded by

sksahoo3852
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
54 views1 page

Self Declaration Income

This document is a self-declaration form where the applicant affirms the truthfulness of the information provided regarding their personal details and family income sources. The applicant acknowledges their responsibility for the accuracy of the declaration and the consequences of providing false information under Indian law. The form also includes sections for detailing various sources of family income and requires the applicant's signature, date, and place of declaration.

Uploaded by

sksahoo3852
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SELF DECLARATION

I, Shri/Smt./Miss……………………………………………..…….…………………………………
Son/Daughter/Wife of …………..………………………………………….………………………………
age………….….years of Village……………………….…..….Po……………..…………………………
PS…………………………………….District Kendrapada in the state of Odisha do hereby
declare that the information given by me in this application form is true to the
best of my knowledge and I have not suppressed / misrepresented any fact.
That I am solely responsible for the accuracy of declaration and information
furnished and shall be liable for action under section 199, 200 and 420 of
Indian penal code and other relevant lows/ Rules in case of furnishing wrong
declaration and information. Also, I am well aware of the fact that the
certificate shall be summarily cancelled and all the benefit availed by me shall
be summarily withdrawn in case of furnishing wrong declaration and
information.

Total income of Family:-

a) From landed property:-


b) From Service:-
c) From Business:-
d) From Plantation:-
e) Daily Wages:-
f) From other Source-
(To be Specified)

Total Income Rs.

Place ………………………..

Date…………………………. Signature of Applicant

You might also like