AND ASSET CERTIFICATE
SELF DECLARATION FOR ISSUE OF INCOME
1 Shri/Miss/Mrs./Smt. Amoresh Dash aged
about 20 yeprs Son/paughter/Wife or Kailash Dash of
Village Nadasla P.S. Nuagawn of Nuagawn
layagarh. do here by declare as follows
Tahasil of District Nlaya
That, I am a native/permanent resident of the above noted address.
vation for SCs, STs, and OBCs and
That, I am not covered under the scheme of reser
the gross annual income of my family for previous
year is below Rs.8.00lakh (Rupees
e, Business, Profession etc.
Eight lakhs) from all sources i.e. Salary, Agricultur
) for
That, my family comes under category of Economically Weaker Sections (WESs
benefit of reservation.
That, my family includes my self my parents and siblings below age of 18years and
also my spouse and children below age of 18years.
That, my family does not own or possess any of the following assets
i. Ac.5.00 of agriculture land and above.
ii. Residential flat of 1000sq. ft. and above.
iii. Residential plot of 100sq yards or 900sq. ft. and above in NACS,
Municipalities and Municipal Corporations.
iv. Residential plot of 200 sq. yards or 1800sq. ft. and above in the areas other
that the urban areas mentioned above at 3(iii).
That, I have made this declaration" to file before the Tahasildar/A
ddl. Tahasildar,
solely
Satybadi for obtaining an Income & Asset Certificate in my favour. That, I am
accuracy of the declaration and information furnished and liable
responsible for the
for action under section 199 and 200 of the Indian
Penal Code in case of wrong
the fact that the certificate shall
declaration and imformation. Also, I am well aware of
availed by shall be summarily
be summarily cancelled and all the benefits
me
withdrawn in case of wrong declaration and information.
Date: 30/05/22 Amoresh Dash
Nua Signature by me
Place:
Noagawn