Self-Declaration Declaration form for issuance of Income Certificate/ nkwdB ;oNhfce/N gqkgs eoB ;pzXh ;t?

x'PDk

I ____________________________Son/Daughter/Wife of __________________________Resident
of______________________________________________District____________________________
Punjab and hereby solemnly declare as under: -
w?A ___________________________ gZ[so$gZ[soh$gsBh ;qh ___________________________________
tk;h__________________________________________ fIbQk ____________________________ਪੰ ਜਾਬ
dh t;Bhe jK ns/ j/m fby/ nB[;ko fpnkB eodk$eodh jK fe L^
1. That I belong to______________ caste, My occupation is ________________ . My and my family’s
income from all sources is Rs._____________________. This income certificate is required for
__________________________ to me or for my minor boy/girl.

fJj fe w?A_______________ iksh Bkb ;pzX oZydh$ oZydk jK. w/ok feZsk__________________ j? . w/oh ns/ w/o/
gfotko d/ ;ko/ t;hfbnK s'A nkwdB__________________ j?. fJj nkwdB ;oNhfce/N w?B{z y[d$ nkgD/ Bkpkfbr
bVe/$bVeh bJh_______________________ b'VhAdk j?.

2. My Family members are as follows/ w/o/ gfotko d/ fBwB nB[;ko w?Apo jB

S. Name /Bkw Age/ Relationship/ Occupation/ezw Income$ PAN CARD

3. That my and my family's annual income from different sources during the last financial year (1ST April
________ to 31ST March________) was as follows/ fJj fe w/oh s/ w/o/ gfotko d/ fgSb/ ftZsh ;kb (1 ngq?b
s'A______ 31 wkou________) d"okB tZy^tZy ;'fwnK s'A ;bkBk nkwdB fBwB nB[;ko ;h.

1 ;oekoh$r?o ;oekoh B"eoh dh fvN/b______________ ns/ T[;dh sBykj s'A e[Zb nkwdB
2 fe;/ th soQK dh g?BPB nkfd s'A eZ[b nkwdB
3 p?eK ftZu fce;v fvgkiN;$;/ftzr p?Ae ykfsnK s'A ftnki dh e[Zb nkwdB
4 r?o^p?fezr ftZsh ezgBhnK ftZu fvgkfiN s'A eZ[b nkwdB
5 y/shpkVh$pkrpkBh tkbh e[Zb IwhB_______ J/eV______ eBkb s'A P[ZX nkwB
6 ewoPhnb gqkgoNh fit/A fe d[ekB, P'n o{w nkfd s'A feokJ/ dh nkwdB
7 fojkfJPh gqkgoNh s'A feokJ/ s'A nkwdB
8 fe;/ th soQK dh d[ekBdkoh s'A nkwdB
9 fe;/ th soQK d/ j'o ftT[gko s'A j'Jh nkwdB
10 fwT{ub czvi$;Nke wkofeN s'A j'Jh nkwdB
11 fe;/ profession fit/A fe vkeNo, tehb, nkoehN?eN, ukoNvnekT{N?AN nkfd s'A gfotkoe
w?ApoK dh ;kbkBk nkwdB
12 T[go'es ftZu eto Bk j'D dh ;kbkBk nkwdB
T[es ;ko/ ;kXBK s'A e[Zb ;kbkBk nkwdB
4. That no certificate of this kind has been issued to me earlier, if issued then it is issued long time ago.

fJj fe w?Bz{ gfjbK nfijk e'Jh ;oNhfce/N ikoh BjhA ehsk frnk j?, i/eo ikohP[dk j? sK T[j pj[s gfjbK dk j?.

5. That there is no any criminal case registered against me for which I have not deprived of from
issuance of this certificate. The information and the reports that are given for issuance of
certificate is true and correct.
fJj fe w/o/ fto[ZX e'Jh th c"idkoh e/; BjhA uZb fojk j? fi; ftu w?B{z fJ; ;oNhfce/N s'A tKM/ oZfynk frnk j't/.w/o/
tZb'A fdsh ;koh doyk;s ns/ T[; ftu doi fog'NK T[es ;oNhfce/N ikoh eoB bJh ;jh dk do[;s jB.

6. I hereby declare that the information given in above and attached documents is true and correct to the
best of my knowledge and belief and nothing has been concealed therein. I know this fact very well that
if any information given by me is found false the I shall be liable for sentence under law and the benefits
given to me on the basis of such information will be withdrawn summarily.

w?A fJZE/ fJj x'PDk eodk$eodh jK fe T[go'es fdZsh rJh ikDekoh ns/ Bkb BZEh d;skt/I w/oh ;wM nB[;ko ;jh
ns/ do[Z;s jB ns/ fJ; ftZu e[ZM th S[gkfJnk BjhA frnk j?.w?A fJBQK sZEK s'A ikD{ jK fe i/eo w/oh e'Jh th fdZsh
rJh ;{uBk rbs fBebdh j? sK w?A ekB{zB ftZu doi ;ik dk jZedko j'tKrk$j'tKrh ns/ w?Bz{ fJ; ;{u Bk d/ nkXko s/
fdZs/ rJ/ bkG tkfg; b? bJ/ ikDr/.

Place$;EkB_________

Dated$fwsh_________

Signature of Declarant ( x'PDk eosk ਦੇ ਹਸਤਾਖਰ)