Court Fee Stamp as required
APPLICATION FORM FOR ISSUANCE OF INCOME CERTIFICATE
(Fields marked * are mandatory)
Service Payment Details : PasteApplicant
1.Service Charges of the kiosk Operator = 18.00 Photo
2.Printing Charges per unit = 10.00
3.Scanning Charges per unit = 5.00
4.The Government fees = 30.00
5.Degs Charges fee = 2.00
(The amount may vary based on no of printing and scaning page counts)
The Acknowledgement of receipt of Application / Delivery of Certificate and
Payments received from the citizens shall be issued free of cost by the CSC operator to the citizens.
Documents Required Applicant’s signatutre
Supporting Documents
1. Salary Certified from the concerned authority. (For Salaried Applicant ).
2. Salary Declaration incorporating all source of income. (For Non-Salaried Applicant).
3. Any other document in support/claim
Delivery Time Lines ; Estimated Timelines To Process The Application (Expected Date of Delivery) :
Fill all the details in the block letters
Personal Details
Applicant Name* :- ___________________ ___________________ ___________________
Gender* :- ___________________ Marital Status*:- ___________________
Date of Birth* :- ___________________ Age* :- ___________________
Parents Details
Father Name* :- ___________________ ___________________ ___________________
Mother Name*
Spouse Details
Spouse Name* :- ___________________ ___________________ ___________________
Relation With Applicant* :- ___________________
Contact Details
Phone No :- ___________________ Mobile No :- __________________
Email :- ___________________
Permanent Address
House No/Name* :- ___________________ Village *:- _______________________________________________
District * :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI Circle * :- __________________
Block * :- ___________________ Police Station * :- __________________
Post Office * :- ___________________ Pin * :- __________________
Submitter Details
Is applicant and submitter are same? * Yes No
Submitter's Name* :- ___________________ ___________________ ___________________
Relation With Applicant* :- ___________________
Purpose * :- ___________________ ___________________ ___________________
Present Address
Is Present Address Same as Permanent Address? Yes No
(If "No" please fill the Present address given below)
House No/Name* :- ___________________ Village *:- _____________________________________________
District * :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI Circle * :- __________________
Block * :- ___________________ Police Station * :- __________________
Post Office * :- ___________________ Pin * :- __________________
Land Record Details
Is ROR Produced? Yes No
(If "YES" please provide the LandRecord Details)
District* :- ___________________ Sub Division * :- __________________
Tahsil * :- ___________________ RI Circle * :- __________________
Police Station * :- ___________________ Mouza(Revenue Village) * :- __________________
Khata No * :- ___________________ Recorded Tenant (Land Owner) * :- __________________
Relation of the applicant with Recorded
Tenant * :- __________________
Plot Details Sl No. Plot No * Area * Kisam *
1
2
3
4
5
Annual Income Details
Salary / Pension Annual Income * :- __________________ Landed Property Annual Income*:- ___________________
Annual Income(Business)
Sl No. Source * Income *
1
2
3
4
Total Income :- --------------------------------------------------------______________
Children Details
School Going Children * :- __________________ College Going Children* :- ___________________
I, Shri / Smt …………………………………………………..………..Son of / Daughter of / Wife of
……………………………………………………………. resident of village ……………………………………..…. P.S.
…………..…………………… District ……………………..………… and particulars stated above are true to the best of my
knowledge and belief and that they are exhaustive and I have not suppressed any fact. In case it is detected later on that any of the facts
stated herein wrong or that I have suppressed some material facts, I shall be liable for prosecution under the relevant law.
Signature of the applicant.
