FORM OF APPLICATION FOR OBTAINING INCOME CERTIFICATE FROM THE DEPUTY     COMMISSIONER  PAPUM PARE DISTRICT 

                                                                        ARUNACHAL  PRADESH

1. Name in full (In block letter)  ..........................................................................................................

2. Father's /Mother's/Gurdian's Husband name ..................................................................................

3. Present Occupation                                      ...................................................................................

4. Village                                                          ..................................................................................

5. Circle                                                           ..................................................................................

6. For whom the certificate is required               ..................................................................................

7. Total number of family members                    ..................................................................................

8. Income per annum with supporting affidavit from HOD/DDO    ......................................................

9. (a)  Other Land holding                                ................................................                  

          (b)  Other sources                                         ..............................................

                        TOTAL PER ANNUM                  ...............................................

10.   Schedule cast/ Schedule tribe                       .......................................................

11.  Purpose for which certificate is sought          ...........................................................

            I declare that the particulars furnished above are true to the best of my knowledge and belief.

VERIFICATION

            I Shri ................................................................................................................. MSM of village under  ................................................................................... Administrative circle verified personally and statement furnished by the applicant are correct to the best my knowledge and belief.

( Name and signature)

ASM (with seal)

        Certified that above particulars furnished by applicant are correct to the best my knowledge and belief.

Date :-.............................................

Place:- ............................................

Signature of concerned Administrative

Officer of the Area

(with seal)