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Self Declaration Form

This self-declaration form is completed by an individual stating their personal details, caste, religion, and annual family income from various sources. The applicant affirms the truthfulness of the information provided and acknowledges the legal consequences of false declarations. The document emphasizes the responsibility of the applicant for the accuracy of the information and the potential cancellation of benefits if found to be incorrect.

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3 views2 pages

Self Declaration Form

This self-declaration form is completed by an individual stating their personal details, caste, religion, and annual family income from various sources. The applicant affirms the truthfulness of the information provided and acknowledges the legal consequences of false declarations. The document emphasizes the responsibility of the applicant for the accuracy of the information and the potential cancellation of benefits if found to be incorrect.

Uploaded by

vivo.work.ai
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 Miss/Sri/Smt ....................................................................................................................................

S/O, W/O, D/O ................................................................................ of Village

.............................................

G.P .................................................... P.S .................................................... Tahasil

.............................................

in the District of ........................................................ do hereby declare that, I am a resident of

Village ........................................................................................ since my birth/marriage i.e,

..................... years.

I have belongs to Caste ................................................ And religion ................................................

Which is

recognized as ................................................ (SC/ST/OBC/SEBC). The annual income of my family

members is Rs. ................................/- only per annum from the sources specified below.

1. Agriculture Rs. ................................/-

2. Salary/Daily Wages/ Remuneration etc. Rs. ................................/-

3. Trade/Business/Profession Rs. ................................/-

4. Other Sources Rs. ................................/-

I do hereby declare that the above information given by me in this self declaration/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 the declaration and information furnished and shall be liable for action
under section 199, 200 and 420 of Indian Penal Code(IPC) 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 all the benefits availed by me shall be summarily withdrawn in case of furnishing
wrong declaration and information.
Signature of Applicant

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