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Form-C - Application/declaration Of The Applicant For Obtaining Income & Backward Class Certificates

Form-C

(See Paras 28.2 and 28.12)

Application/declaration of the applicant for obtaining Income & Backward Class

Certificates

I _______________Son/daughter of _______________ age_______R/o Village

_____________ Tehsil____________District______________ declare that my family income

consisting of the following members, whose particulars are given, is as under:

Sr. No.

Name

Relationship to the Address Occupation/Category

Detail of Property

Applicant

of backward classes

owned.

(i) Agricultural

(ii) Non- Agricultural

7. Annual family income from:-

(i) Salary

(ii) Business

(iii) Agriculture/Horticulture etc.

(iv) House Property.

(v) Other sources.

I certify that the total annual income of my family from all sources is Rs._________________________.

I________________solemnly declare that facts as stated above are true to the best of my knowledge. I shall be liable for

prosecution, if the facts given above are found incorrect.

Kindly issue Income/ Backward class certificate in my favor.

Place: _____________

Signature of the applicant.

Dated: _____________

Form-C - Application/declaration Of The Applicant For Obtaining Income & Backward Class Certificates