nghUshjhuj;jpy; eype;NjhH rhd;W (EWS Certificate) ngw tpz;zg;gk;.

mDg;Geh;

_____________________________________
_____________________________________
_____________________________________
_____________________________________

ngWeh;

tUtha; tl;lhl;rpaH mtHfs;>

________________________________ tl;lk;.

Iah>

ehd; Nkw;fz;l Kfthpapy; trpj;J tUfpNwd;. vdJ FLk;g

tUkhdk; `________________ MFk;. ehd; ___________________________
,dj;ijr; NrHe;jtuhNtd;. vdJ kfd;/kfs; _________________________
vd;gtUf;F kj;jpa muR gzpf;F tpz;zg;gpf;f nghUshjhuj;jpy;
eype;NjhH rhd;W (EWS Certificate) rhd;W toq;FkhW jq;fis
jho;ikAld; Nfl;Lf;nfhs;fpNwd;.

,g;gbf;F

ehs; :- ________________________
 kDjhuH thf;F%yk;

________________________ khtl;lk;> _____________________________ tl;lk;>

_____________________________________ fpuhkj;jpy;> fjT vz; ______________ y;
______________________ njUtpy; trpj;JtUk; ___________________________________
kfd;/kidtp ____________________________ vd;gtH ______________________________
fpuhk epHthf mYtyH Kd;G nfhLf;Fk; thf;F%yk;.

ehd;> vdJ kfd;/kfs; __________________________ vd;gtUf;F kj;jpa muR

gzpf;F tpz;zg;gpf;f nghUshjhuj;jpy; eype;NjhH rhd;W (EWS Certificate) rhd;W toq;ff;
Nfhhp kD nra;Js;Nsd;. vdJ FLk;g ml;il vz; (Smart Card No)
________________________________ MFk;. ehd; __________________________________
,dj;ijr; NrHe;jtuhNtd;.

jw;rkak; ehd; ______________________________ Ntiy nra;J FLk;gj;ij

fhg;ghw;wp tUfpNwd;. mjd; %yk; vdJ FLk;g Mz;L tUkhdk; `__________________
MFk;. vdf;Fk; vdJ FLk;g cWg;gpdHfSf;Fk; NrHj;J nkhj;j tptrha epyq;fs; 5
Vf;fUf;F Nky; ,y;iy. vdf;F nrhe;jkhf xU ___________ tPL cs;sJ. mjd; gug;G
_____________ MFk;. ,ijj; jtpu vdf;Nfh my;yJ vdJ FLk;g cWg;gpdHfSf;Nfh>
jkpo;ehl;by; ve;j xU efuj;jpYk;/fpuhkj;jpYk; tPNlh tptrha epyq;fNsh vJTk; ,y;iy
vd cWjpAld; $wpf;nfhs;fpNwd;.

ehd; jtwhd jfty; nfhLj;J ,jd; %yk; nghUshjhuj;jpy; eype;NjhH rhd;W

(EWS Certificate) rhd;W ngw;wpUg;gjhf gpd;dH njhpa te;jhy;> muR vd; kPJ vLf;Fk;
rl;lg;gbahd eltbf;iff;F fl;Lg;gLNtd; vd cWjpAld; $wpf;nfhs;fpNwd;.

ehd; NkNy $wpa thf;F%yk; vd;Dila Ra epidTld; vd;dhy; nfhLf;fg;gl;lJ

vdTk;> Nkw;gb thf;F%yj;jpy; ehd; cz;ikf;Fg; Gwk;ghf VjhtJ $wpapUe;jhy;> mJ
gpd;dhspy; ngha; vd njhpa tUkhapd;> ,jd; %yk; ehd; mile;j mD$yq;fs;>
gad;fs; midj;ijAk; ,of;f NehpLk; vd;gij ed;F mwpNtd; vd;Wk;> vd; kPJ rl;lg;gb
eltbf;if vLf;fyhk; vd cWjpAld; $wpf;nfhs;fpNwd;.

jq;fs; cz;ikAs;s

/vd; Kd;ghf/
 fpuhk epHthf mYtyH mwpf;if

________________________ khtl;lk;> _____________________________ tl;lk;>

_____________________________________ fpuhkj;jpy;> fjT vz; ______________ y;
______________________ njUtpy; trpj;JtUk; ___________________________________
kfd;/kidtp ___________________________________________ vd;gtH jdJ kfd;/kfs;
__________________________________ vd;gtUf;F kj;jpa muR gzpf;F tpz;zg;gpf;f
nghUshjhuj;jpy; eype;NjhH rhd;W (EWS Certificate) rhd;W toq;ff; Nfhhp kD
nra;Js;shH;. mtuJ FLk;g ml;il vz; (Smart Card No) _______________________
MFk;. kDjhuhpd; kfd;/kfs; ______________________________ ,dj;ijr; NrHe;jtuhthH.
rhjpr; rhd;W efy; ,izf;fg;gl;Ls;sJ.

kDjhuH kw;Wk; mtuJ kidtp __________________________________ gzp nra;J

mjd;%yk; FLk;g Mz;L tUkhdk; `__________________ <l;LfpwhH. (muRg;gzp vd;why;
rk;gsr; rhd;W ,izf;fg;gl;Ls;sJ).

kDjhuUf;Fk; mtuJ FLk;g cWg;gpdHfSf;Fk; NrHj;J nkhj;j tptrha epyq;fs;

5 Vf;fUf;F Nky; ,y;iy. (gl;lh ,izf;fg;gl;Ls;sJ). kDjhuUf;F nrhe;jkhf xU
___________ tPL cs;sJ. mjd; gug;G _____________ MFk;.

,ijj; jtpu kDjhuUf;Nfh my;yJ mtuJ FLk;g cWg;gpdHfSf;Nfh> NtW

efuj;jpNyh my;tJ fpuhkj;jpNyh tPNlh tptrha epyq;fNsh vJTk; ,y;iy vd kDjhuH
cWjpnkhop mspj;Js;shH.

Nkw;gb tpz;zg;gk; Fwpj;J kDjhuhplKk; kw;Wk; fpuhkg; nghJ kf;fsplKk; chpa

tprhuiz nra;ag;gl;lJ. kDjhhplk; thf;F%yKk; ngwg;gl;L ,j;Jld;
,izf;fg;gl;Ls;sJ. vdNt> Nkw;gb tprhuizapd; mbg;gilapy; kDjhuhpd; kfd;/kfs;
______________________________ vd;gtUf;F nghUshjhuj;jpy; eype;NjhH rhd;W (EWS
Certificate) toq;fyhk; vd ghpe;Jiu nra;ag;gLfpwJ.

fpuhk epHthf mYtyH

 tUtha; Ma;thsH mwpf;if

________________________ khtl;lk;> _____________________________ tl;lk;>

_____________________________________ fpuhkj;jpy;> fjT vz; ______________ y;
______________________ njUtpy; trpj;JtUk; ___________________________________
kfd;/kidtp ____________________________________________ vd;gtH jdJ kfd;/kfs;
__________________________________ vd;gtUf;F kj;jpa muR gzpf;F tpz;zg;gpf;f
nghUshjhuj;jpy; eype;NjhH rhd;W (EWS Certificate) rhd;W toq;ff; Nfhhp kD
nra;Js;shH;. mtuJ FLk;g ml;il vz; (Smart Card No) _______________________
MFk;. kDjhuhpd; kfd;/kfs; ______________________________ ,dj;ijr; NrHe;jtuhthH.
rhjpr; rhd;W efy; ,izf;fg;gl;Ls;sJ.

kDjhuH kw;Wk; mtuJ kidtp __________________________________ gzp nra;J

mjd;%yk; FLk;g Mz;L tUkhdk; `__________________ <l;LfpwhH. (muRg;gzp vd;why;
rk;gsr; rhd;W ,izf;fg;gl;Ls;sJ).

kDjhuUf;Fk; mtuJ FLk;g cWg;gpdHfSf;Fk; NrHj;J nkhj;j tptrha epyq;fs;

5 Vf;fUf;F Nky; ,y;iy. (gl;lh ,izf;fg;gl;Ls;sJ). kDjhuUf;F nrhe;jkhf xU
___________ tPL cs;sJ. mjd; gug;G _____________ MFk;.

,ijj; jtpu kDjhuUf;Nfh my;yJ mtuJ FLk;g cWg;gpdHfSf;Nfh> NtW

efuj;jpNyh my;tJ fpuhkj;jpNyh tPNlh tptrha epyq;fNsh vJTk; ,y;iy vd kDjhuH
cWjpnkhop mspj;Js;shH.

Nkw;gb tpz;zg;gk; Fwpj;J kDjhuhplKk; kw;Wk; fpuhkg; nghJ kf;fsplKk; chpa

tprhuiz nra;ag;gl;lJ. kDjhhplk; thf;F%yKk; ngwg;gl;L ,j;Jld;
,izf;fg;gl;Ls;sJ. fpuhk epHthf mYtyhpd; mwpf;ifAk; ngwg;gl;L ,j;Jld;
,izf;fg;gl;Ls;sJ.

vdNt> Nkw;gb tprhuizapd; mbg;gilapy; kDjhuhpd; kfd;/kfs;

______________________________ vd;gtUf;F nghUshjhuj;jpy; eype;NjhH rhd;W (EWS
Certificate) toq;fyhk; vd ghpe;Jiu nra;ag;gLfpwJ.

tUtha; Ma;thsH
 GOVERNMENT OF TAMILNADU
REVENUE DEPARTMENT

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS

Certificate No: ___________ Date: _____________

VALID FOR THE YEAR _________________

1. This is to certify that Shri/Smt/Kumari __________________________________________

son/daughter/wife of __________________________________________ permanent resident of
_________________________________________________________________________ Village,
________________________________ Taluk, _________________________________ District,
in the state of TAMILNADU, Pin code ________________ whose photograph is attested below
belongs to Economically Weaker Sections, since the gross annual income* of his/her family** is
below ` 800000/- (Rupees Eight Lakh only) for the financial year __________________. His/her
family does not own or possess any of the following assets***.
I. 5 Acres of agricultural land and above,
II. Residential flat of 1000 sq. ft and above,
III. Residential plot of 100 sq. yards and above in notified municipalities,
IV. Residential plot of 200 sq. yards and above in other than the notified municipalities.

2. Shri/Smt/Kumari ______________________________________________ belongs to the

___________________________________ caste which is not recognized as a Scheduled Caste,
Scheduled Tribe and Other Backward Classes (Central List).

Recent Passport size

attested photograph of
the applicant

(Signature with seal of Office)

Name _____________________________
Designation ________________________

--------------------------------------------------------------------------------------------------------------------------------
*Note 1 Income covered all sources i.e salary, agriculture, business, profession etc.
**Note 2 The term 'Family' to this purpose include the person, who seeks benefit of reservation, his/her parents and siblings below the age of
18 Years and also his/her spouse and children below the age of 18 years.
***Note 3 The property held by a 'Family' in different locations or different places/cities have been clubbed while applying the land or property
holding test determine EWS status.
 GOVERNMENT OF TAMILNADU
REVENUE DEPARTMENT

INCOME & ASSET CERTIFICATE TO BE PRODUCED BY ECONOMICALLY WEAKER SECTIONS

Certificate No: ___________ Date: _____________

VALID FOR THE YEAR _________________

1. This is to certify that Shri/Smt/Kumari __________________________________________

son/daughter/wife of __________________________________________ permanent resident of
_________________________________________________________________________ Village,
________________________________ Taluk, _________________________________ District,
in the state of TAMILNADU, Pin code ________________ whose photograph is attested below
belongs to Economically Weaker Sections, since the gross annual income* of his/her family** is
below ` 800000/- (Rupees Eight Lakh only) for the financial year __________________. His/her
family does not own or possess any of the following assets***.
I. 5 Acres of agricultural land and above,
II. Residential flat of 1000 sq. ft and above,
III. Residential plot of 100 sq. yards and above in notified municipalities,
IV. Residential plot of 200 sq. yards and above in other than the notified municipalities.

2. Shri/Smt/Kumari ______________________________________________ belongs to the

___________________________________ caste which is not recognized as a Scheduled Caste,
Scheduled Tribe and Other Backward Classes (Central List).

Recent Passport size

attested photograph of
the applicant

(Signature with seal of Office)

Name _____________________________
Designation ________________________

--------------------------------------------------------------------------------------------------------------------------------
*Note 1 Income covered all sources i.e salary, agriculture, business, profession etc.
**Note 2 The term 'Family' to this purpose include the person, who seeks benefit of reservation, his/her parents and siblings below the age of
18 Years and also his/her spouse and children below the age of 18 years.
***Note 3 The property held by a 'Family' in different locations or different places/cities have been clubbed while applying the land or property
holding test determine EWS status.