Application Form For Passport Economically Weaker Section Income Certificate ee For tho Financial yoar 2021-22 Seen Applicant Detail Applicant Name Father Name Gender Male / Female Date of Birth Caste Category Sub Caste Category Present Addres: Village: Post Office Pin Code Police Station Revenue Circle: Lovality/Landmark: District State: Postal Address Is same as Permanent Address: Village Post Office Pin Code: Police Station, Revenue Circle’ Locality/Landmark: District State: Income Details": Gross Annual Income includes Salary, Agriculture, Business, Profession etc., for the financial year prior to the year of application (Applicant/His/Her Family"): (In Rupees) Assets Information (Applicant! His/Her/Family"): i, 15 Bigha of agricultural Land and above in tur ii, 1 Bigha of residential land and above in rural area, Yes/N iii. 1.5 Katha of land in notified Municipal Corporation’ Municipal Board! Town Commitee area. Yes/No iv. House of built up area more than 1000 Sq. fit and above in notitied Municipal Corporation/ Municipal Board’ Town Committee area, Yes/No Note : The term “Family * for this purpose will include the person who seeks benefit of Reservation , His/Her parents and siblings below the age of 18 years as also His/Her spouse and children below the age of 18 years. Note: “I hereby declare that the above mentioned information is furnished on best of my knowledge. If information & declaration is found false, | am liable for prosecution, Idon't belong to SC, ST and OBC Caste. Date: Signature of the Applicant Mobile No: Scanned with ComScannerANN REA GOVERNMENE OL ASSAM OFFICE OF THE CIRCLE OFLICER DERGAON REVENUE CIRCLE: DERGAON, INCOME & ASSEST CERTIFICATE [0 BE PRODUCED BY ECONOMICALLY WEAKER SECTION (For seat in educational Institutes and post under Gove, OF ssn) No.DCD(Ceniticate) 6/2019-20: Dated Dergaon, the . 2021 VALID FOR THE YEAR 2021-22 This is certify that Shri-Smti Son Daughter’ Wife of — Shri'l ate permanent resident of cesses seceetee Olffice, sees Distei of Golaghat in the State of Assam, in Code seseeeseeceeee . Whose photograph is attested below belongs of Heonomically Weaker Sections, since the gross annual income* of histher family** is below Ro. 8 Lakh (Rupees Eight Lakh ) only for the financial year 2021-22. His / her family dose not own of possess any of the following assets "** . 15 Bigha of agricultural I.and and above in rural arca. ii, 1 Bigha of residemtial land and above in rural area. iii, 1.5 Katha of land in notified Municipal Corporation’ Municipal Board Town Commitee area, iv. House of built up area more than 1000 Sq. fit and above Municipal Corporation’ Municipal Board/ Town Committee ar Village. Post notified Shri’Smti/Kumari.. belongs to the Caste which is not recognized as a Schedule Caste‘lribe and Other Backward Classes (In the State of Assam) ignature with Seal Offiver. Photograph I Name... Designation *Note 1. Income covered all sources ic. salary, agriculture, business. profession ete. ** Note 2, The term “Family * tor this purposed include the person. who secks benelit af reservation his/her parents and siblings below the age of 18 years as also his‘her spouse and children below the aye of 18 years. “** Note 3. The property held by a “Family” in different locations or differen places’ cities have belong clubbed while applying the land or property holding test to determine EWS statu ‘Scanned with CamSeanner