APPLICATION FORM FOR ISSUANCE OF INCOME CERTIFICATE
(Fields marked * are mandatory)
Documents Required
Mandatory Documents
Paste Applicant
1. Proof of Identity of Applicant - Voter ID / Aadhaar Card / PAN Card / Passport.. etc * Photo
2. Income declaration / Salary Certificate / Income Tax Returns document (Any one document) *
Supporting Documents
1. Copy of ROR
2. Any other document in support/claim
Delivery Timelines
Estimated Timelines to Process the Application (Expected Date of Delivery) - 10 Working Days
(Expected date is calculated excluding holidays)
Fill all the details in the block letters
Personal Details
Applicant Name* :- ___________________ ___________________ ___________________
Gender* :- ____________________ Marital Status*:- ___________________
Date of Birth* :- ___________________ Age* :- ___________________
Aadhar Number :- ___________________ Religion :- ___________________
Phone No :- ____________________ Mobile No:- ___________________
Email Id :- _________________________________________________
Parent’s Details
Father Name* :- ___________________ ___________________ ___________________
Mother Name* :- ___________________ ___________________ __________________
Permanent Address :- o Urban o Rural
Applicant residing outside Odisha? If Yes -
State* :- ____________________
District * :- ___________________ Sub Division * :- ____________________
Tahsil * :- ___________________ RI Circle * :- __________________
Village * :- ____________________ GP /ULB :- ___________________
House no. / Street Name :- ___________________ Police Station * :- __________________
Post Office :- ___________________ Pin :- __________________
Family Members / Guardian Details (In case of minor or person unable to manage his/her own affairs)
If any other person other than applicant filling the Application? * o Yes o No
(If "Yes" please fill the Present address given below)
Relation With Applicant* :- _______________________________________
Submitter's Name* :- ___________________ ___________________ ___________________
Present Address :- o Urban o Rural
Is Present Address Same as Permanent Address? o Yes o No
(If "No" please fill the Present address given below)
State * :- __________________
District * :- ___________________ Sub Division * :- ____________________
Tahsil * :- ___________________ RI Circle * :- __________________
Village * :- ____________________ GP /ULB :- ___________________
House no. / Street Name :- ___________________ Police Station * :- __________________
Post Office :- ___________________ Pin :- __________________
Land Record Details
Is ROR Produced: o Yes o No
Gross Annual Income of the Family (During Preceding Financial Year)
Agriculture (including plantation, horticulture, dairying, poultry, fisheries etc.) :- ________________________________
Salary / Wages / Remuneration etc. :-________________________________
Trade / Business / Profession (Please Specify) :-________________________________
Other Sources (Please Spaecify) :-_________________________________
Total Income (In Rs.) :-________________
Purpose* :- ___________________________________________________________________________________
Declaration
I do hereby declare that the information given by me in this application form is true to the best of my knowledge and I have
suppressed / misrepresented any fact. That, I am solely responsible for the accuracy of the declaration and information furnished
and shall be liable for the action under section 199, 200 and 420 of Indian Penal Code and other relevant laws / rules in case of
furnishing wrong declaration and information. Also, I am well aware of the fact that the certificate shall be summarily cancelled
and all the benefits availed by me shall be summarily withdrawn in case of furnishing wrong declaration and information.
I Agree :- _____________________ Place:-________________________
