a ‘HEA STE ATTESTATION FORM teareet/ warning aa Ww are ag) (1) rere ont a ats sae quer tara eat aes GET ankar yet | ROA ear ch eh Ae ats Fre ses wT ante feetarei area efit fear sara The furnishing of false information or suppression of any actual PLEASE _AFFIX| information in the Attestation Form would be a disqualification & is YOUR RECENT| likely to render the candidate unfit for employment under the PASSPORT —SIZE| Government. PHOTOGRAPH, | @) STW aaa aie wega wea hare a sechean at Raa ‘bar se, eT Y ae, eet Fea sae tr ee ee eA er set a TT are FS ag eT A eGa Poar aan Ry Car a aa oe ge area BTSH wT ‘Sarr wag TTT If detained, convicted, debarred, etc, subsequent to the completion and submission of this form the detail should be communicated to the Staff Selection Commission or the authority to whom the Attestation Form has been sent earlier, as the case may be, failing which it will be deemed to be suppression of factual information. (8) aR seatecare a arenes A Reh mare ae ere ara PHA HATTA AA ANE TIT ae dh titer Feat areas Guar at arent at sae dar was aT ARATE Ifthe fact that false information has been furnished or that there has been suppression of any factual information in the attestation form comes to notice at any time during the service of a person, his services would be liable to be terminated, 140) Name in full (N BLOCK/CAPITAL LETTERS) with aliases i any SRT a" Aenea se afta (ee HRA) ‘SAeITA/SURNAME ‘aTA/NAME ‘Re a aT/FATHER'S NAME. (6) Please indicate if you have added or dropped in at any stage any part of your name or surname / TA TAT 5 A ITT ATT STAT A HH HO SST & SNA HO CTT H 2. Present address in full, (i.e.Village, Thana & District, House No., Lane/Street/Road & Town) & name of Dist. Headquarters (ACT GRU Ta 3c ait, er a AR a aa oe ATH fa 3(a) Home address in ful, (Le-ilge, Thana & District, House No, Lane/Street/Roed & Town) & name of Dist, Headquarters. /O a QUA Feel aay, Mea TA ar ae areata A aaa a are SMe: (b) W originally a resident of Pakistan the address in that Country andl the date of migration to Indian Union, /2& apres & creates frat at era a ae eer ee rare@ 4a) Sot eat eater & (Fraer A sraeT aT) eT ST Ree tr A ae a A flr TT era ae ater a ere aon eee Toe Her eet a tt eT 3 21 AY 3 AT wether nn a ait stat TH ee aH Particulars of places (with periods of residence) where you have resided for more than one year at a time during the preceeding five years. In case of stay abroad (Including Pakistan) particulars of all places where you have resided for more than one year after attaining the _age of 21 years, should be given. ‘rarer &Y ratty aa a we ca FROM TO ‘rare aT GT Ge ga as, arat atk rer weet aya 3 erp, ay Residential address in full (ie. Village, Thane & Dist. or House No. Lane/Street/Road & Town) ued wlan A seats eat & Bor yeaa wr ay Name ofthe Dist. Headguarters ofthe place mentioned in the preceeding column, (b), amjneme [ardaat [ae aTlaatated alam aera ar (area 8 arte | Feet ®t at cq at ara | ada a | san/ sift | Place of | athe araerar amr | (af eater | Permanent Bynationity |" —— |i capa | ser |Home (by birth & or (if employed give | ser et at by Domicile) esignation and | official address) ih ar sre Present Postal address (if dead, give last address) rar a agra ate "ay Father's name & full address Ta/ Mother sah ie Wife's Husband's 41$/ Brothers) SEAR) Sisters)@ 8. ait ames ge atte grat faeer a steerer ae weet et at ae ark at aif aa a ‘Se/information to be furnished with regards to Son(s) and or Daughter(s) In case they are studying/lving in a foreign country. ‘T/Name ‘Tegra (oe A we) fare ae A Hea ae | Ted ae A eee Te rarer B)/ Nationality | Wet serra RT se | ee A fee are s (by birth or by domicile) | BFFA/ Country in which | HEMT #X E/E B/ studying/iving with full | Oate from which address studyingfiving inthe country mentioned. in previous column ‘TETTAT/Nationalty 2: a) se AY Date of Birth : (oy aarraayeresent age : (¢) Afegaeer’s wera aTa/Age of Matriculation = 8 (a) Sewer Rene TA SN TTT aT eT aR RITE Place of Birth, Dist. & State in which stuated- (se Re ate ase ara aT sRT ARTE Distt. & state to which you belong: (3a fae a areata arate rar ae a pS PraTaN Distt. & State to which your Father originally belong, 9 (a) 391 7 Your Religion (b) ar aa aerate sTfa serial b, sree aera oh 1 a eh a Sere a eT? ‘Are youa member of a Scedul Scheduled Tribes? Ans. "Yes" or Ifthe Ans is "Yes" state the name thereof 10. erora: ara gets ert 15 a Bega ae YS Ate are ae Eat a a RAT eararsre/ Educational Qualification showing places of education, with years, in Schools and Colleges since the age of 15 qrometa wutata | oetfate | oat ster Name of School/Colege with full | Date of entering | Date of leaving | Examinations passed address“ 234 (a) are gare ete are aera ar Sea a at ft aera eT startet anc a arta aie ged ah ath atch Rg A arts ier Serer GT ReaOT Rearsrei ‘Are you holding orhave at any time held an appoinment under the Central or State Government or Semi Government or Private Fitm oF Institution? If so, give full particulars with dates of employment, up to date. [eB/Period we fate oe arm fer ar |arciaa, ol, deena | ate otsd a TO Birrom [aero | wearer | TERT TAH Full Name | Reasons for leaving Designation, emoluments | & address of the | Previous service and nature of work handled | employer 12(b) AAR STE I ATT AAT BY HN ATT ST TST AT Heit eT Saari eare rere /faeaaqreray renter rarer a ater ated AY et athe attr FA tar (areerct dey frerarrett 1965 @ Feros after aera eh Pat ae ara sare om aT aie dane att) tg eh at aa aaa RBrarw ag areprrrreaen archer AY ange aa Bar wa aaah Fare eres cere aA Behe Bee TE Te AY TTT A IMT He HATE TA HT PT are BTR BT TERT Tt NS STOTT aT TT? Ifthe previous employment was under the Government of India/a State Govt/An Undertaking owned or controlled by the Govt. of India or a State Govt/An Autonomous Body /University /Local Body. If you had left service in giving a month's notice under Rule-5 of the Central, Civil Services(Temporary service) Rules, 1965 or any similar corresponding rules where any disciplinary proceedings framed against you, or had you been called upon to explain your conduct in any matter at the time you gave notice of termination of service, or at a subsequent date, before. =—=-your services. actually —_terminated: 12, (a) a are aah Rrra te aT? Bet Have you ever been arrested? Yes/No (by sar srerver Pret reer Fae seed sat ta Pa? tient Have you ever been prosecuted? Yes/No (@ FaaneeeAREAT Ere? ttt Have you ever been kept under detention? Yes/No (ql) am are a weet A ee TE? eae Have you ever been fined by a Court of Law? Yes/No (¢) a area Ht sad eat TS? ttt Have you ever been convicted by a Court of Law for any offence? Yes/No (0 san ara aah Pet genera a areyare eaeT aT BRA tiatt Have you ever been bound down? Yes/No6) (g) a arts Serer ear STATA eA AT FATT rate aha re are? watt Have you ever been debarred disqualified by any Public Service Commission for any ofits Examination/Selection? Yes/No (hy) a arrerent Faveht srveraere ate eM eae Fehr eta a Fee ATT srettre efit Paver aren ever sera ftte Per sre? att Have you ever been debarred from any examination or rustcated by any University or any other Educational Authority Institution? Yes/No (0 Sa carer ee rea es ree eT HASH TAT TTR erat tsany case pending against you in any Court of Law atthe time of filing up these Attestation Forms? Yes/No aR setae aa Reet nee ar see ea ta ETAT a a a gr Fee rar ga a a BY HE ETT Breage era sears & rect aera areata 2? att [Is any case pending against you in any University in any other Educational Authority/ Institution atthe time of filing up these Attestation Forms? Yes/No atz/Note 1. rer ge caer eh ts ori at tng, erect ay ater FAT STE Please also see the warning at the top ofthis Attestation Form, ae rear ee 2 oer ene wT aT eT aN TE PLAT TEL Specific answers to each of the questions should be given striking out "Yes" or "No" as the case may be 13, eh aha) Fasten caret aaa Poet SN seat See et [Names of two responsible persons (not in blood relation) of your locality or two references to whom you are known. Mention address and telephone no as well an e BE rans ace fas AY eae atc rear ae Berar a BE SH TOA aT a are era ag a ae ate Fae A Se ATE; en | certity thatthe foregoing information is correct and complete to the best of my knowledge and belief. 1 am not aware of any circumstances which might impair my fitness for employment under Government _seshecare GETER/Signature of Candidate: arity Date Faa/Place© ‘SRST STOTE/|DENTITY CERTIFICATE (carer arenes fer a Pat wm a ZAR CETERA Bla ART) (Certificate to be signed by anyone of the following) i afta srrarerseracere de rorafte afer Gazetted Officers of Centra or State Government iam arta sa char ae a se Re tng a agen oat seat ser sah reer eae: OTT EY Members of Parliament or State Legislature belonging to the Constituency where the Candidate or his parent I guardian is ordinarily resident. ii, arg aroharderfoert afore Sub-Divisional Magistrate/Officers iv, antares ae ee TRL ATA ST ARNT Tehsildar or Naib/ Deputy Tehsidars authorized to exercise Magistrate powers view oes emanate % starsat set arse 3 Ror arearee fra by Principal Head Master of the recognised School/Cllege/ Institution where the candidate stusied last vi, Woe Rees arftra/Block Development Officer vii, SHECHTERTY/ Post Master ‘viii, Tarra fatter /Panchayat inspector saan Fa eT RSH AY ANATGAMTY Se argc ayaa afin a eae ec gts re ger Fe ae POT A ate PTT ET ATE Certified that, | have known Shri/Smt./Kum. Son/ Daughter? Wife of Shi CEC eg ‘Months and that tothe best of my knowledge and belief the particulars furnished by him her are correct. ‘FaTe/Place: ‘ear aerenr aer aTy, TETEY, ETATT AAT TAT Name, Designation, Signature and Address of the Competent Authoity ‘Reitayoat sera ganr at ar ag i Rastaad after ara, eee gra SIC MET ATERAFEN, athe, saps, iat-0020, Name, Designation & full address Addl. Commissioner of income Tax (HQ) of the Appointing Authority Personnel & Technical, Aayakar Bhavan, ‘Mumbs-400020 se Fra iv aoe Rrareter Post for which the candidate is. being considered” fits /Personne! [ATT STTH/ Aayakar Bhawan fa$/Mumbai-400020 A eceqarer ag utes ra {PI hereby declare that Barca artes E.am a Chizen of india 2 seh arenas see ar aeeT A 2/21 | was not a member of any unlawful organization 23 Psat artes Sear ar mee a & the A Hh al ite eee iron A faa A aration {am not a member of any unlawful organization and | shall not take part in activities of any unlawful organization. 2 ve a rr a eae ree et eae Ihave not been convicted by the Court of Law for any offence. 2 at aera tae at TAN a eo ee at aoa a Hear fet eA ere aah Rher Tela He at GY Fareh Tamera aeichever a aenvaveY A Hea eo 3A aT Oped aercar A warren atta bt seh Berra Pre Ga artaa a FST | shall not be a member of, or be otherwise associated with, any political party or any ‘organization which takes part in poltics nor shall | take part in, subscribe in ai of, or assist in any other manner, any political movement or activity. Hai ae eer aT Fv Fv aR ST ahr ga a EET ETE | further declare that | am not a member of Provincial Unit of Territorial Army. ‘Haifa Reet! | am Unmarried/ married, FERRITE cn cee RAI ne BRUT aug aerator ht Se ert aixs ae PHT. ce aed fra aargl 1 take the appointment as in Mumbai Income Tax Dept, on service conditions laid down in the Mumbai Income Tax Dept, Offer of Appointment No. dated ea AR aa a ane h seat aaa HIONTA/ STEN as Wega TET | will produce the Domicile Certficate/Adhar Card on/within @ month of 2 eer aan ae agh ware Rar Se EPEC areca ear gl | accept the seniority in the cadre of inorder of ranking assigned to me by the Staff Selection Commission. ey/Place: areal eee) Raer/oate SIGNATURE OF THE CANDIDATE1. Hap earhegent ‘BIWOM/Declaration rest sicher eb sraneer A |, Shri /Smt./ Kum. declare as under Pea aifeeritey/faeR/aereT EI That | am unmarried/ a widowr/ a widow. Prat Ranta Fed AT ew ARE THE That | am martied and have only one wife living, RH Renita € ae AT Aes ara H aeepAN AT af Haag aH Aa Teoh ET BL That | am married and my husband has no other living wife to the best of my knowledge. fi a Reenter ate AY rer eae & aftr ofesat & are A ye fare ote Te aarti That | am married and have more than one wife living. Application for grant of ‘exemption is enclosed. te ear & Ranier & Rett Gh A wo area afer aise ta sega ged fae antea eda That | am married to a person who has already one wife or more living ‘Application for grant of exemption is enclosed, A enertta agate & fren halt aiRar/ger Sah ore cH Hider siete at, T Ferre ag ae | will not_marry any woman/ man having a living husband/ wife without Government's consent. Hereafter & see eho a ear whe wh etn eT & wa A RTT | RA ae weare AY gare A ag choonat A aNg gE ong arch tat A dar saa Are TY ae enrgem I solemnly affirm that the above declaration is true and I understand that in the event of the declaration being found to be incorrect after my appointment, I shall be liable to be dismissed from service. ‘faa /Date. atzjniote eaTETE/signature 1, Fraanpr ead weet eT RTS Please delete the not applicable clauses. 2. sree Gi) ae ( Applicable in the case of Clauses (i), i) & (ii) only.9) rc errr aero arto ert Frere fre Ferree aah iy eM ATT VERIFICATION FORM FOR CANDIDATES UNDER CONSIDERATION FOR APPOINTMENT TO A SUBORDINATE SERVICE UNDER THE GOVT. OF INDIA. 4, at A fafa & foe area & erga santa aca & Rs Ket see eat sa aa 1, a candidate for the appointment to hereby certify that my answers to the following questions are correct. a. ar ae gee gk aa arr rah iter aaah e eat Have you previously been employed by the Central or any Provincial Government? Yes/No ‘one aera ater Fe 9 rer eh rae se seere rae Beer Fe et aT Department or Office in which previously employed. Designation of appointment. Reasons for termination of appointment. bara aera race ake a rae as ‘fare area Fare fret ae aT aT TE eT Bret Have you previously applied without success for any appointment under the central or a provincial Government? Yes/No fener srrar arta fara rar ores a Bre a cert Faas Fe ard Fra ara Department or office in which Designation of appointment applied for an appointment was sought A argrer Fra Sachre aaet Kea ere ical A rere eb ita reer Pet fee et arate et) T understand that if the above statement is false in any material respect my appointment is liable to be terminated. FaT/Place! FRAT Date: oneene BeaTTe/Signature10(A) sR HTT /CHARACTER CERTIFICATE seein rar rat aya paey party sect Aypratr BRIE ce TES HA/AA E Co TT AS TTT after soon go me pre ATC aR CARN Ye ETAT Ng ath Ta TB FEE urefra dar tq sates wferaneer axa eI Certified that, | have known Shri/Smt./Kum. ‘Son/ Daughter of for the last years Months and that to the best of my knowledge and belief he /she bears a reputable character and has no antecedents which will render him/ her unsuitable for Government employment. sa preg aaraag dieragt Shvi/ Smt. Kur isnot related to me reH/Place: rarer sifted ar a Ue RECTAN) GAZETTED OFFICER'S NAME & SIGNATURE “I@AITA/DESIGNATION... ‘Feni/pate: ‘rte eH OFFICE ADDRESS: 1048) ‘WRGLWTTTH/CHARACTER CERTIFICATE, spain ear Sat 6 ATELY party sect Aare eae a. eS TA ee AS TT ‘are rear aca FF ae aT rw CT TTT we ge NG act Ca a St SE sree ear arate er aT Certified that, | have known Shri/Smt./Kum. ‘Son/ Daughter of for the last years Months and that to the best of my knowledge and belief he /she bears a reputable character and has no antecedents which will render him/ her unsuitable for Government employment. apogee _ Aer aag eae Shri/ Smt. Kum. is not related to me. PAM /Place: ... rar are Ta we BTR GAZETTED OFFICER'S NAME & SIGNATURE ‘fatih/Date: “TEATAT/DESIGNATION. ‘aretfere TAIT/OFFICE ADDRESS... ws(ay ‘SRST STOTEA/DENTITY CERTIFICATE eer rarer Ft Aa Fat («rear serene a ener ERR rar AT (Certificate to be signed by any one of the following(*) Competent Authorities) covalent del diet ti Ie PIRATE oe ena serena ar PR .... - prety Wee Ewe ag aft sobre Rear oe & fle stator ‘aes wearer vd Het wenita Fl gare oeaTT Are. Certified that, | have known Shri/Smt./Kum. Son/ Daughter/ Wife of Shri Tor the last years Months who is residing at ‘and itis also certified that the signatures and photograph attested below are of Shri/Smt. / Kum. His/Her— Idetiication marks are aaa waft an aR afta aeatter adic tet (3H (aaa) we ot ow (Gignature of Candidate) ‘ATONE &) Recent Photograph duly attested by competent authority with seal (partly on photograph and partly ‘on the certificate) RRMA YPC: enn are frat aA, SAT, CTA AAT TAT Name, Designation, Signature and Address of the Competent Authoity ‘Reitayoate:. iL Reser rsr acer raha aft Gazetted Officers of Central or State Government ii, am are sa dha ae db ase Rarer aftwe a ager oe avez area se are ores area: rave HRY Members of Parliament or State Legislature belonging to the Constituency where the Candidate or his parent I guardian is ordinarily resident. ii, re Ramee Sub-Divisonal Magistrate/Otficers iv. arr everett ear ee ge TRAE ST TAY I TACT] Tehsldar or Nab Deputy Tehsldars authorized to exercise Magistrate powers ¥.AIRTaT Sst wrarapemeaeM & srartaeraearse set seal a aie srearaa Part Principal Head Master of the recognised School/ College/ Institution where the candidate studied last vi, Gos Rewer aiftaTE/Block Development Officer vii, SIECHTERT/ Post Master ‘viii, Terra fatrera/Panchayet inspectorINSTRUCTIONS TO BE FOLLOWED Please read the instruction carefully and keep a blank copy extra before filling the Attestation Forms. Please bring four sets of Attestation Forms duly filled in ORIGINAL with complete address and pin code details Page 6 consists of Identity Certificate which has to be signed by Gazetted Orficer of ‘Central or State Government and the same officer should sign the first Character Certificate on page 10(A), Page 10(B) consists of Second Character Certificate which has to be signed by different Gazetted officers and the same officer should sign another Identity Certificate on page UL. Please note both the Gazetted officers must be different as mentioned in the serial number 3 and 4 above. Al the 4 attestation forms should be filled identically. Failure to comply with the instructions would lead to undue delay in appointment.File No. CANDIDATE'S STATEMENT AND DECLARATION The candidate must make the statement required below prior to his/her Medical examination and must sign the declaration appended thereto. His/her attention is specially directed to the warning contained in the Note at the end of page 2. 1 | Name in full{ in capital letters) 2 | State your age & place of birth 3a). | Have you ever had Small Pox intermittent or any other fever, enlargement of glands, spitting of blood, asthma, heart diseases, lung disease, and appendicitis? (b). | Any other disease or accident required confinement to bed and medical or surgical treatment 4 [When were you last vaccinated 5. | Have you or any of your near relative been afflicted with consumption, scrofula, gout, asthma, fits epilepsy or insanity? 6 | Have you suffered from any form of nervousness due to overwork or any other cause? 7 | Have you been examined & declared unfit for Government service by Medical Officer/Medical Board, within the last 3 years? 8 _ | Furnish the following particulars concerning your family Father's age ifliving | Father'sageat | No. of brothers No. of brothers dead, &state of health | death & cause of | living their ages, & | their ages at death & death state of health cause of death Page 1 of 3Mother’sage | Mother's age] No. of sisters living their | No. of sisters dead, their ifliving& | atdeath& —_| ages, & state of health _| ages at death & cause of state of health | cause of death death I declare all the answers given on the reverse to be, to the best of my belief and knowledge correct and true. 1 also solemnly affirm that I have not received a disability certificate / pension on account of any disease or other conditions. Candidate's signature Candidate's signature (In presence of Medical Officer) e : Signature of Medical Superintendent/ Civil Surgeon/ Chief Medical Officer Note:- The candidate will be held responsible for the accuracy of the above statement. By wilfully suppressing any information he will incur the risk of losing the appointment, and if appointed, of forfeiting any claim to superannuation allowance or gratuity. Page 2 of 3CERTIFICATE 1 hereby certity that I have examined Shri/Smu/Miss a candidate for employment in the Income-Tax Department and cannot discover that he/she has any disease (communicable or otherwise) constitutional weakness or bodily infirmity except 1 do not consider this a disqualification for appointment in the office of the Addl Commissioner of Income-Tax (HQ) Personnel, Mumbai. Her/His age according to his/her own, statement is. Years and by appearance about Years. Marks of identification:- Signature of Medical Superintendent/ Civil Surgeon/ Chief Medical Officer Name Regd. No. Degree Address Signature of the candidate inside thebox ‘THIS FORM SHOULD BE FILLED IN BY BALL PEN BY THE DOCTOR Page 30f3CANDIDATE’S DETAILS FORM Name of candidate Alias, if any Father's Name Mother’s Name Marital Status Name of Spouse (If Married) Blood Group Place of Birth Date of Birth Gender Mobile No (candidate) Mobile No (parents) Candidate’s E-mail ID Aadhar No. Nationality Religion Present Address : Present Address Duration | From: Month Year (in month & year) To: Month Year Permanent Address : Permanent ‘Address | From: Month Year Duration (in month & year) _| To: Month Year Any other address (if any) : Page 1 of 2Other Address Duration (| From: Month Year in month & year) To: Month Year Police Station District Educational Qualification (PG/Graduate/UG/below Secondary/Others) Details of course Criminal History (Yes/No) Category (GEN/SC/ST/OBC/PH/VH/HH/OH) Any other information : Photo Identity Proof |[_] PAN Card (1 Driving Licence (Enclose any Two) (2) Election ID (4) __Aadhar Card Residential Address Proof |[_] Passport (1 Electricity bill {Enclose any Two) (Telephone bill (landline) [<] Ration card ( Passbook ()_ Utility bill (2) _ Rent Agreement (2) Others Date: Candidate Signature Place: Page 2 of 2