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Self Declaration Form for Income and Land

The document is a self-declaration by Digbijaya Dhal, affirming the truthfulness of the information provided regarding personal details, family background, and income. It states that no family member is employed by the government and outlines land ownership and caste information. The applicant acknowledges responsibility for the accuracy of the declaration and the consequences of providing false information.

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d.bijayadhal
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13 views1 page

Self Declaration Form for Income and Land

The document is a self-declaration by Digbijaya Dhal, affirming the truthfulness of the information provided regarding personal details, family background, and income. It states that no family member is employed by the government and outlines land ownership and caste information. The applicant acknowledges responsibility for the accuracy of the declaration and the consequences of providing false information.

Uploaded by

d.bijayadhal
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

Digbijaya Dhal
I, Sri/Mrs./Miss_______________________________________________________
Janmajaya Dhal
Son/Wife/Daughter of____________________________________________ 21
age _________of
Andhia
Village: ____________________________________________ PS. Bhadrak(Rural) in the district
Bhadrak
SAMBALPUR do hereby declare that the information given by me in this application form and its
self-attested enclosures is true to the best of my knowledge and that the information furnished is
exhaustive and I have not suppressed any fact. That, I am solely responsible for the accuracy of
the declaration and information furnished and liable for action under Section 199 and 200 of the
Indian Penal Code in case of wrong declaration and information.

(1) That, no one of my family is serving in State Government or Central Government as regular
or contractual basis.
(2) Andhia
I have no land in urban area except Village_________________________________
(3) General
I belong to ___________________ Hindu
by Caste and _______________________ religion.
(4) Father
My___________________ 1,80,000
Annual Income is Rs. _______________________
(5) Parsuram Dhal
That Sri______________________________________ Grandfather
is my______________________
and the recorded tenant.
(6) That Sri __________________________________ and ___________________________
Is one and same person by name and surname.

Andhia
Mouza______________________________ 201
Khata No:__________ 1.0200
Area______________
Mouza______________________________ Khata No:__________ Area______________

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 wrong declaration and
information.

(Signature of the Applicant)

DIGBIJAYA DHAL
Name (Block Letter)_____________________________

At/Po:Andhia Block:Bonth
Address:____________________________
Place: Andhia PS: Bhadrak(Rural)
Date: 28.09.25 District: Bhadrak

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