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Self Declaration for Sambalpur Residents

The document is a self-declaration form where the applicant declares that the information provided is true and accurate. They acknowledge sole responsibility for the accuracy of the information and potential legal penalties for false declarations. The applicant also declares that no family members work for the state or central government, they own no urban land except for the listed village, and provide their caste, religion, and annual income.

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binodkumarnayak82
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3K views1 page

Self Declaration for Sambalpur Residents

The document is a self-declaration form where the applicant declares that the information provided is true and accurate. They acknowledge sole responsibility for the accuracy of the information and potential legal penalties for false declarations. The applicant also declares that no family members work for the state or central government, they own no urban land except for the listed village, and provide their caste, religion, and annual income.

Uploaded by

binodkumarnayak82
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
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SELF DECLARATION

I, Sri/Mrs./Miss_______________________________________________________

Son/Wife/Daughter of____________________________________________ age _________of

Village: ____________________________________________ PS. in the district


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) I have no land in urban area except Village_________________________________
(3) I belong to ___________________ by Caste and _______________________ religion.
(4) My___________________ Annual Income is Rs. _______________________
(5) That Sri______________________________________ is my______________________
and the recorded tenant.
(6) That Sri __________________________________ and ___________________________
Is one and same person by name and surname.

Mouza______________________________ Khata No:__________ 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)

Name (Block Letter)_____________________________

Address:____________________________
Place: PS:
Date: District:

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