CERTIFICATE

SELF DECLARATION OF SEBC

CHANDRA SAHe
ISri/ME-AKumani4Smt.KRUSHNA
S/OWIO of Jatadlhari
Sahoo
aged about_30years
_P.O.Dhanitrci
Village Anasarta

P.S. KonaK_ in the District Pu do here by solemnly afifm

and declare as under

1. That, Iam a permanent resident of Village Ana saura

u n d e r1 0 p Tahasil.

That, I belong to SEBC community and my sub-caste is judia

2
as per settlement ROR stands recorded in the name ofJatadkart hoo
S/O. Manu Sahoo vide Khata No.481/175

of Village AnasarRa
That, My Annual income is Rs. from Agricultural Land / Income
3

from Service Rs. and Income from Business/Others Sources

Rs total income of Rs.

(in word Only

4. That, The SEBC certificate is required for Study/ Service purpose of imtne.

I 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 knowiedge and that the inforrgation
furnished is exhaustive and I have not suppressed any fact. That, I am solely respons ible 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. Aiso,
am well avware of the fact that the cerificate shalil be summarily cancelled and allthe
benefits availed by me shall be summarily withdrawn in case of wrong declaration and infor

mation.

Krshna Chandca Sahoo

Signature of the Applicant