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Self Declaration

This document is a self-declaration form for applicants to provide personal and financial information for various categories including income and asset details. It includes sections for demographic information, income sources, and a declaration of truthfulness regarding the provided information. The applicant acknowledges responsibility for the accuracy of the information and potential legal consequences for any misrepresentation.

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Nsp Odisa
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5 views1 page

Self Declaration

This document is a self-declaration form for applicants to provide personal and financial information for various categories including income and asset details. It includes sections for demographic information, income sources, and a declaration of truthfulness regarding the provided information. The applicant acknowledges responsibility for the accuracy of the information and potential legal consequences for any misrepresentation.

Uploaded by

Nsp Odisa
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

RESIDENT S.E.B.C S.C I.A.C. (Center)


INCOME O.B.C S.T. I.A.C. (State)

Salutation:- Shri Smt. Miss.

Name of the Applicant


Gender
Marital Status
Age
Mobile No.
Father’s Name
Mother’s Name
Spouse’s Name
Present Address:- District:-
Tahasil:- R.I Circle:-
Village:- Posta Office:-
Police Station:- PIN Code:-
Residing at Present Address:- Year Month
Permanent/Parental Address:- if same District:-
Thasil:- R.I Circle:-
Village:- Police Station:-
Purpose:-
ROR Details: Mouza:- Khata No. Rel^with R.T
Sub-Caste:-S.E.B.C/O.B.C/S.C/S.T.
GROSS ANNUAL INCOME OF THE FAMILY (DURING PRECEDING Genealogy (R.T to Applicant)
FINANCIAL YEAR):
1. Agriculture
2. Salary/Daily Wages/Remuneration etc.
3. Trade/Business/Profession (Please Specify)
4. Other Source (Please Specify)
TOTAL INCOME:
Asset Details for E.W.S Area in Acre Location
1. Agriculture Land (Family Share)
2. Residential Plot/ Flat (Family Share)

I do hereby declare that the information given by me in this application form are all true to the best of
my knowledge and have not suppressed/ misrepresented any fact. That, I am solely responsible for the accuracy
of the declaration and Informatics furnished and shall be liable for action under section 199, 200 and 420 of
Indian Penal Code and other relevant laws/ rules in case furnishing wrong declaration and information. Also I
am well aware of the fact that the certificate shall be summarily cancelled and the benefits availed by me shall
be summarily withdrawn in case of furnishing wrong declaration and information.

Full Signature of Applicant / Guardian

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