ServicefitC* Income Certificate/ nill-ren Hdcllddd

Facilitation Charge/ arruilatio tl chi 75 U.

Government Fee/ rid en Nil/ ro-8
Total Fee/413
. 75 U.

List of Required Documents / trti rt tra

Documents, mentioned in the following list, are to be scanned from only original documents and to be
uploaded online. / 6 1.1j1 yd1 We. elidgt11 frra:a niFIF tHdRtl i Tra-6 and' 1-11 t1
46772115nRit3 r4d6' t
Whether
Mandatory/
S.No
Name of Documents/ tki. ri er 31- Optional/'He /
NM*.
fgrga
Proof of Identity and Proof of Address/Residence of Beneficiary
(As per the Punjab government notification no. E-
64139/2GR2/423 Dated :25-11-2021)/ 231-0-113a e" LOTT ET iii.d. Mandatory / zicidi
1
I'd 1-4 / led' fee e J-11:1 (LIBT'a ildoi'd @. ?)ardakie tau E-
64139/2GR2/423 1-ra 25-11-2021 111-6111-d)

3 Self-declaration / H -41-61- ft-rd Mandatory / Had.

4 Verification Report / irielci faitaz Mandatory / Wdai

5. Photo of Beneficiary / ETT-F3ait c Mandatory / Wdt

-Self-Declaration Declaration form for issuance of Income Certificate/ YrITHEW HOC rZae 1P-13 ado Frarft

Son/Daughter/Wife of Resident
of District
Punjab and hereby solemnly declare as under:
114d-Krifelizsot i41
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fUT tr4rEi
cH6 a uF n-r4 36 fF3-4 nr-6g'3 Myr-5 «de iaa-
et u fa :-
1. That I belong to caste, My occupation is . My and my family's
income from all sources is Rs. . This income certificate is required for
to me or for my minor boy/girl.
feu 612,5 Frgrc
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2. My Family members are as follows/ Lrfavra3 I5His nr-o-Frra ThEra- do

S. Name /6r/f Age/ Relationship/ Occupation/dR Income/ PAN CARD

No/ @HU fir
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654
t

3. That my and my family's annual income from different sources during the last financia year (1 ST April
to 31ST March ) was as follows/ ftu fa- l'aft 4 44 tifd---ra- 3 firms f4d1 Wet (1 )111-15
31 HTUU ) ti-tri Fafnir 41 HO'6 WITFE6 I6H-6 )1161-I'd H11

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4. That no certificate of this kind has been issued to me earlier, if issued

then it is issued long time ago.
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5. That there is no any criminal case registered against me for which I have not deprived of from
issuance of this certificate. The information and the reports that are given for issuance of
certificate is true and correct.
fEru f .;.."cr flierdel ()-1 hder 4e6 faata fm fed Pt' feH Hdelre ff-tpicr fapw
EM feAl -graft EabrgT3- nig 12-Fr fTa e--eRfdt eo(d Hzi01 H'dl -a'-d- Fel mil eid)-H (36 I
6. I hereby declare that the information given in above and attached documents is true and correct to the
best of my knowledge and belief and nothing has been concealed therein. I know this fact very well that
if any information given by me is found false the I shall be liable for sentence under law and the benefits
given to me on the basis of such information will be withdrawn summarily.
fErU ZibTaT Oid'eliaTe 'at fa 91-ftg w31 art ti ieW di n-13 61e5 ttin. ee-H td FfHs3
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7. By this self-declaration, I undertake to keep the certificate file with me till the issuance of the certificate
and thereafter and by the office, whenever the file is called for or in any court case. If necessary, I will
present my file at this office or in any court, wherever the file is required.
feH na_ taw, ibu didl to- feel mat V. fa Hdelydae HtJ+d1 rETESI-IdC d ..t 'd as nig r g
anue tarrut 8 thcarFidaratnr-4 H#tTarl-g el )4'-dr a1 d1 ti' fl fool ag-e t,rfed arElics. zI Hd cid
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Place/ma

Dated/W

Signature of Declarant ( OM-War uartra)

 Verification Report for Issuance of Income Certificate

I solemnly declare that I Son/Daughter/Wife of

Shri R/o

belong to caste and permanent resident of Punjab, My occupation is

and no member of my family is servicing in any Govt. Department. My and my family
incomes from all sources are Rs. This income certificate to me or my minor boy/girl.

L1--sup:isulp-rae 111-

fans al jrMa II cte5 444 utter/4/2T ni.J.1?-

gra eye tar/ilal E el

fois Er nra 3-10- ufavra z d 1 ablau HdcPcil faarar f'•cr N-ae ea

adc/aae 01 )-14 1112. )1-4 1-reaVra +-'a nfrliT6 0I fEd
bin-rea ;Ida Ue11-6. 14E Ma /z3-5-4. gter

Declarant/03MM qa3T

Declaration from Nambardar/Sarpanch/MC

Nambardar/Sarpanch/MC R/o solemnly

declare that Son/Daughter/Wife of
Shri Rio

is permanent resident of the given address and I personally know

the declarant and belongs to caste. His/her occupation is
His/her income is below than Rs.
. This verification report is made only for the
purpose of income certificate.

Abide d/Ffal-M/t131-
fEngr5
/aue fa 1-1 tr-de

4o/fn au a 6HAla a Nal-la cany6 ciddr t rlidl 12. a Hier'/H'tel Utnla.

rl d
cY8 Htf4 al Her C43T tta eT vl-re6 u4E 1 vler OI Thu ursizs fuau
taus nrn-ru6 Hdt dQd t )-I3V t r aT EfrEk diet

Signature of Nambardar/Sarpanch/M.C./

Report Concerned Patwari: 'Wd

- u pour treat&
Sr. No./0.41 e)elcf Dated/fire / /

Report Concerned Patwari:/ f , Nzve

Signature: Circle Patwari/DTrertrff peer Wane