GOVERNMENT OF ARUNACHAL PRADESH

OFFICE OF THE DEPUTY COMMISSIONER

P A S I G H A T

APPLICATION FORM FOR INCOME CERTIFICATE

1. Name :-

2. Father’s name :-

3. Address :-

4. Occupation :-

5. Yearly Income :-

6. Whether Govt. servant :-

If so, then whether certificate

form DDO enclosed & Income

indicated. :-

7.Agriculture land owned & location.

8. Whether holding Trade licence in

name of self or family members if

so , details.

I certify that the above particulars are true. If any particular is found false,

legal action may be taken against me.

Signature

NOTE

The applicant must produce one of the following documents :-

1. Certificate from BDO reg Inclusion in BPL list.

2. Certificate from DDO in case of Govt servants.

3. Affidavit from self reg Income.

CERTIFICATE

( Reg BPL)

Certified that Shri/Smti __________________________________ is

included in the BPL list of _________________ Block at Sl. No. ________________ , village _________________________ .

B . D. O.

CERTIFICATE

( For Income of Govt. Servants )

Certified that Shri/Smti _______________________________________

is a Permanent / Temporary / W.C./ Casual employee of __________________ Deptt.

holding_________________________ post and his / her income as per records is

Rs. ___________________ / Year.

D.D.O.