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APPLICATION FOR ECONOMICALLY WEAKER SECTIONS

Self
APPLICANT DETAILS: Attestation
Applicant Name* :
Relationship: (S/O,D/O,W/O) * :
Gender (M/F/TG)* :
Date of Birth :
Mobile No*: :
Phone No: :
Email ID: :
Aadhaar No*: :
Ration Card No: :
Caste*: :
Purpose of Income Certificate*: :
(Civil Posts & Services/ Admission in
Educational Institution)
PERMANENT ADDRESS:
Door No :
Locality / Land Mark :
District* :
Mandal* :
Village* :
Post Office* :
Pin Code* :

DETAILS OF ASSETS:
Agriculture Land Details: Available Not Available
Enter below details if Available:
PPB PPB Total
Name of Relationship Extent Name Name Name
Survey Number Number Income
Sl.No the with the in of the of the of the
No / Khata / Khata from land
Pattadar applicant Ac.Gts District Mandal Village
No. No. holding
1
2

Residential Property Details (Flats / Apartments): Available Not Available

Enter below details if Available:
Relations Total
Name Extent Notified Name of Name Name
Sl. hip with Details of Munici Income
of the in Sq. Municipal the of the of the
No the Property pality from the
owner ft ity District Mandal Village
applicant property
1
2

Residential Property Details in notified Municipality (Plot): Available Not Available

Enter below details if Available:
Total
Name Relationshi Notified Name of Name of Name of
Sl. Details of Extent in Income
of the p with the Municipal the the the
No Property Sq. yards from the
owner applicant ity District Mandal Village
property
1
2

Residential Property Details in other than notified Municipalities (Plot): Available Not Available
Enter below details if Available:
Name Relationship Name of Name of Name of
Sl. Details of Extent in Total Income
of the with the the the the
No Property Sq.yards from the property
owner applicant District Mandal Village
1
 2
SOURCE OF INCOME:

Income from Employment: Available Not Available

Enter below details if Available:

Sl. Name of Relationship Employer Whether State /Central /public Place of Annual
No the with the Details Sectors / private Sector org. Working Income
employee applicant
1
2

Income from Business / Profession, etc.:

Enter below details if Available:

Sl. Name of the employee Relationship with Name & Address of Firm / Nature of Annual
No with designation the applicant Company / Organization etc., Business Income
1
2

Declaration:
I hereby declare that my family income from all sources for the financial year prior to the year of
application is below Rs. 8 Lakhs.
I hereby declare that my family does not own or possess any of the following assets:
1. 5 Acres of agricultural Land and above
2. Residential flat of 1000 sq. ft. and above
3. Residential plot of 100 sq. yards and above in notified municipalities
4. Residential plot of 200 sq. yards and above in areas other than the notified municipalities
I hereby declare that the above mentioned information is furnished on best of my knowledge. If
information & declaration is found false, I am liable for prosecution.

Documents List:
1. Application Form *(PDF Format)
2. Ration Card/Aadhaar Card/EPIC Card *(PDF Format)
3. Recent Passport Size Photograph * (JGEG Format)
4. Signature of the Parent / Guardian *(JGEG Format)
5. Applicant Signature *(JGEG Format)

Yours faithfully,
Name of the Signature
of the Parent/Guardian (Signature of the Applicant)
(* - indicates mandatory)

Note:
1. As per the Director, Ministry of Personnel, Public Grievances and Pensions, Department of
Personnel and Training, New Delhi, Government of India Memo. No. 36039/1/2019-Estt (Res)
even Dated: 21.01.2019 and 31.01.2019, “the property held by a “Family” in different
locations/places/cities shall be clubbed to determine the E.W.S. status”.
2. If it is found that the information submitted by the Applicant is fake/false, further action shall be
taken against him/her under the provision of Indian Penal Code.
3. Income covered all sources i.e., salary, agriculture, business, profession, etc.
4. 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.