Department of Revenue

Issuance of Income Certificate

Official Use Only ਕੇਵਲ ਦਫਤਰੀ ਵਰਤ ਲਈ nko Nh n?; ;oft; e'v /RTS Service: 10

Application Number / noIh ਨੰਬਰ : Date of Application / noIh ਦੀ ਿਮਤੀ

Name of Block & Tehsil /ਬਲਾਕ /ਤਿਹਸੀਲ ਦਾ ਨ

Fields marked with asterisk (*) are mandatory/ ਿਜਹੜੇ ਫੀਲਡ ਤੇ ਤਾਰਾ fuzB (*) ਲਿਗਆ ਹੈ, T[j ਭਰਨ ਜਰੂਰੀ ਹਨ
Part – 1 Personal Details / ਿਵਅਕਤੀਗਤ ਵੇਰਵਾ

Details of Person Filling the Application Form / noIh ਫਾਰਮ ਭਰਨ ਵਾਲੇ ਿਵਅਕਤੀ ਦਾ ਵੇਰਵਾ
1. Name / ਿਬਨਕਾਰ ਦਾ ਨ Self Attested Photo of
2. Address / ਿਬਨਕਾਰ ਦਾ ਪਤਾ Beneficiary
bkGgkso dh ;t?^s;dheP[dk
3. Relation with Beneficiary / ਿਬਨਕਾਰ ਦਾ ਲਾਭਪਾਤਰ c'N'
ਨਾਲ ਿਰਸ਼ਤਾ
Personal Data of Beneficiary / ਲਾਭਪਾਤਰ ਦਾ ਿਵਅਕਤੀਗਤ ਡਾਟਾ
4. Name / ਨ *
5. Gender / ਿਲੰਗ * Male / ਪੁਰਸ਼ Female / ਔਰਤ
6. Date of birth / ਜਨਮ ਿਮਤੀ 7. Age (if Date of birth not known)/
ਉਮਰ (ਜੇਕਰ ਜਨਮ ਿਮਤੀ ਨਹੀ ਪਤਾ)
8. Place of Birth / ਜਨਮ ਅਸਥਾਨ
9. Father's Name / ਿਪਤਾ ਦਾ ਨ *
10. Mother's Name / ਮਾਤਾ ਦਾ ਨ
11. Address / ਪਤਾ *

PIN Code / ਿਪੰ ਨ ਕੋਡ District / ਿਜ਼ਲਾ *

12. Marital Status / ਿਵਆਹ ;fEsh 13. Spouse Name / ਪਤੀ / ਪਤਨੀ ਦਾ ਨ
14. Email ID / ਈਮੇਲ ਆਈ ਡੀ 15. Contact Phone Number /ਸੰ ਪਰਕ
ਲਈ ਫੋਨ ਨੰਬਰ *
16. Voter ID Card Number / ਵੋਟਰ ਆਈ ਡੀ ਕਾਰਡ
ਨੰਬਰ
17. Aadhaar Number (UID) / nkXko ਨੰਬਰ (ਯੂ ਆਈ Aadhaar Enrollment Number (if
Aadhaar not issued)/ nkXko ਇਨਰੋਲਮਟ
ਡੀ)
ਨੰਬਰ (ਜੇਕਰ nkXko ਨੰਬਰ ਜਾਰੀ ਨਹ ਹੋਇਆ)

Part – 2 Service Details / ਸੇਵਾ ਦਾ ਵੇਰਵਾ

Application Details / noIh ਦਾ ਵੇਰਵਾ

□ Sewa Kendra / ਸੇਵਾ ਕਦਰ

18. Mode of Delivery of Service/ ਸੇਵਾ ਦੀ ਅਦਾਇਗੀ ਦਾ ਤਰੀਕਾ *
□ By Post/ ਡਾਕ ਦੁਆਰਾ

19. Application processing Office / ਅਰਜੀ ਕਾਰਵਾਈ ਦਫ਼ਤਰ

Service Details / ਸੇਵਾ ਦਾ ਵੇਰਵਾ

Last Rev: Aug 2017 Page 1 of 9

20. Occupation
21. Monthly Income from all sources (Including Family Income)
22. Reason for the Issuance of Income Certificate

Part -3 List of Required Documents / ਜ਼ਰੂਰੀ ਦਸਤਾਵੇਜ ਦੀ ਸੂਚੀ . Please tick (√) the document attached / ਿਕਰਪਾ ਕਰਕੇ ਨੱਥੀ ਦਸਤਾਵੇਜ ਨੂੰ ਿਟੱ ਕ (√) ਕਰੋ

1 Report from concerned Patwari & Nambardar / Sarpanch Mandatory

/ M.C. /;pzXs gNtkoh$Bzpodko$;ogzu$n?wH;h s'A fog'N

2 Self Declaration from Applicant Mandatory

fpB?eko s'A ;t?^x'PDk gZso

3. Residence Proof – Voter Card / Driving License / Mandatory

Electricity Bill.

e'Jh th d' fojkfJPh d/ go{c t'No ekov$vokfJftzr

bkfJ;?A;$fpibh fpb

4. ID proof – Aadhar Card./ gfjukD gZso nkXko ekov Mandatory

5. Copy of Income Proof from all resources/ ;ko/ t;hfbnK s'A Mandatory
nkwdB go{c dh ekgh

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I confirm that I have been residing in India for at least 182 days in the preceding 12 months &
information (including biometrics) provided by me to the UIDAI is my own and is true, correct and
accurate. I am aware that my information including biometrics will be used for generation of Aadhaar
and authentication. I understand that my identity information (except core biometric) may be provided to
an agency only with my consent during authentication or as per the provisions of the Aadhaar Act. I
have a right to access my identity information (except core biometrics) following the procedure laid
down by UIDAI. / w?A s;dhe eodk jK fe w?A fgSb/ 12 wjhfBnK ftZu xZN'FxZN 182 fdBQK s'A Gkos

ftZu ofj fojk jK ns/ w/o/ tb'A :{ankJhaJ/avhankJh B{z fdZsh rJh ;{uBk (;w/s pkfJUw?fNqe) mhe tk
do[Z;s j? . w?A fJ; sZE s'A ikD{ jK fe w/oh ;{uBk (;w/s pkfJUw?fNqe) gqwkfDe ns/ nXko pDkT[D
bJh tosh ikt/rh . w?B{z gsk j? fe gqwkfDesk d'okB w/oh fJj ;{uBk (f;tkJ/ e'o pkfJUw?fNqe d/),
fe;/ th J/iz;h B{z w/oh ;fjwsh Bkb iK nXko n?eN d/ T[gpzXK nB[;ko jh gqdkB ehsh ikt/rh .
:{ankJhaJ/avhankJh tb'A fBoXkos gqfefonk ngDkT[D T[gozs w?B{z nkgDh fJ; ;{uBk (f;tkJ/ e'o

pkfJUw?fNqe d/) sZe gj[zu dk jZe jk;b j? ਅਤੇ ਮ ਸੱਚੇ ਿਦਲ ਿਬਆਨ ਕਰਦਾ / ਕਰਦੀ ਹਾਂ ਿਕ ਉੱਕਤ ਵੇਰਵੇ

ਸਹੀ ਹਨ ਅਤੇ ਕੋਈ ਜਾਣਕਾਰੀ ਛੁਪਾਉਣ / ਗਲਤ ਿਬਆਨੀ ਲਈ ਮ ਿਨੱ ਜੀ ਤੋਰ ਤੇ ਿਜੰਮੇਵਾਰ ਹੋਵਾਂਗਾ / ਹੋਵਾਂਗੀ

Citizen’s Signature / ਿਬਨੈ ਕਾਰ ਦੇ ਹਸਤਾਖਰ

Last Rev: Aug 2017 Page 3 of 9

 Self-Declaration

I _____________Son/Daughter/Wife of Sh________________Resident of________________________

District SAS Nagar, Punjab and hereby solemnly declare as under:-

w?A _________________gZ[so$gZ[soh$gsBh ;qh _________________ tk;h _____________________ fIbQk dh t;Bhe jK ns/

j/m fby/ nB[;ko fpnkB eodk$eodh jK fe L^

1. That I belong to______________ caste, My occupation is ________________ and no member of my

family is servicing in any Govt. Department My and my family incomes from all sources are
Rs.________. This income certificate is required to me or for my minor boy/girl_______________.
fJj fe w?A_______________ iksh Bkb ;pzX oZydh$ oZydk jK. w/ok feZsk j? ns/ w/o/ gfotko dk e'Jh
th wA?po ;oekoh ftGkr ftu B'eoh BjhA eodk$eodh j?. w/o/ ns/ w/o/ gfotko d/ ;ko/ t;hfbnK s'A
nkwdB_______________ j?. fJj nkwdB ;oNhfce/N w?B{z y[d$ nkgD/ Bkpkfbr bVe/$bVeh bJh
b'VhAdk j?.
2. That no certificate of this kind has been issued to me earlier, if issued then it is issued long time ago.
fJj fe w?B{z gfjbK nfijk e'Jh ;oNhfce/N ikoh BjhA ehsk frnk j?, i/eo ikohP[dk j? sK T[j pj[s
gfjbK dk j?.
3. That there is no any criminal case registered against me for which I have not deprived of from issuance of
this certificate. The information and the reports that are given for issuance of certificate is true and
correct.
fJj fe w/o/ fto[ZX e'Jh th c"idkoh e/; BjhA uZb fojk j? fi; ftu w?B{z fJ; ;oNhfce/N s'A tKM/ oZfynk
frnk j't/.w/o/ tZb'A fdsh ;koh doyk;s ns/ T[; ftu doi fog'NK T[es ;oNhfce/N ikoh eoB bJh ;jh
dk do[;s/

Self- Declarant (x'PDk eosk)

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I hereby declare that the information given in above and attached documents is true and correct to the best of my
knowledge and belief and noting has been concealed therein. I know this fact very well that if any information given by
me is found false the I shall be liable for sentence under law and the benefits given to me on the basis of such
information will be withdrawn summarily.

w?A fJZE/ fJj x'PDk eodk$eodh jK fe T[go'es fdZsh rJh ikDekoh ns/ Bkb BZEh d;skt/I w/oh ;wM nB[;ko ;jh tk do[Z;s
jB ns/ fJ; ftZu e[ZM th S[gkfJnk BjhA frnk j?.w?A fJBQK sZEK s'A ikD{ jK fe i/eo w/oh e'Jh th fdZsh rJh ;{uBk rbs
fBebdh j? sK w?A ekB{zB ftZu doi ;ik dk jZedko j'tKrk$j'tKrh ns/ w?B{z fJ; ;{uBk d/ nkXko s/ fdZs/ rJ/ bkG tkfg; b? bJ/
ikDr/.

Place$;EkB

Dated$fwsh

Self- Declarant (x'PDk eosk)

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 Declaration form for issuance of Income Certificate

nkwdB ;oNhfce/N ikoh eoB bJh x'PDk gZso ckow

I solemnly declare that I _______________________ Son/Daughter/Wife of Shri____________________

R/o___________________________________ belong to___________ caste and permanent resident of Punjab, My

occupation is ______________ and no member of my family is servicing in any Govt. Department. My and my family
incomes from all sources are Rs.______________. This income certificate to me or my minor boy/girl.

Declaration from Nambardar/Sarpanch/MC

I ____________________Nambardar/Sarpanch/MC. R/O___________________________solemnly declare that

______________________Son/Daughter/Wife of Shri_________________________

R/o___________________________ is permanent resident of the given address and I personally know the declare and
belongs to _____________________ caste. His/her occupation is __________________

And he/she has no any type of cultivated land area. His/her income is below than Rs._______________.

This verification report is made only for the purpose of income certificate.

Signature of Nambardar/Sarpanch/M.C./ Bzpodko$;ogzu$n?wH;h d/ j;skyo

w?A ._______________.g[Zso$g[Zsoh$gsBh ;hq._______________. tk;h Bkb fpnkB ehsk j? fe w?A iks Bkb ;pzX oZydk$oZydh
ns/ gzikp dk$dh gZek$gZeh t;Bhe jK w/ok feZsk ns/ w/o/ gfotko dk e'Jh th w?Apo ;oekoh ftGkr ftu B"eoh BjhA eodk$eodh
j?. w/o/ ns/ w/o/ gfotko d/ ;ko/ t;hfbnK s'A nkwdB j?.fJj nkwdB ;oNhfce/N w?B{z y[d nkgD/ Bkpkfbr bVe/$bVeh bJh
b'VhAdk j?.

fpnkB eosk

w?A Bzpodko$;ogzu$n?wH;h th;h Xow Bkb fpnkB eodk$eodh jK fe g[Zso$g[Zsoh$gsBh ;qh tk;h dk gZe/$gZeh s"o s/ t;Bhe j?
ns/ w/o/ fpnkB eosk B{z iksh s"o s/ ikDdk$ikDdh jK ns/ iks Bkb ;pzXs j?. T[; feZsk j?.

ns/ T[; e'b fe;/ th fe;w dh y/spkVh G{wh dk y/so BjhA T[; dk $T[; dh nkwdB o[gJ/ s'A xZN j?.fJj gVskb fog'N f;oc
nkwdB ;oNhfce/N d/ wzst Bjh pDkJh rJh j?/.

Last Rev: Aug 2017 Page 6 of 9

Sr. No./ bVh Bzpo___________ Dated/ fwsh:

Report Concerned Patwari:/ fog'N, jbek gNtkoh

Signature: Circle Patwari/ j;skyo jbek gNtkoh

nkwdB ;oNhfce/N gqkgs eoB ;pzXh ;t? x'PDk

w?A _______________________ g[Zso$g[Zsoh ;qh__________________________________________ tk;h

____________________________________________________________________B{z y[d$nkgD/ p/N/$p/Nh

bJh_______________________ ;pzXh fJBew ;oNhfce/N b'VhAdk j?. w?A fJj ;t?^x'PDk eodk$eodh jKL^

1H fe w?A iBob e?Nkroh$nB[;{fus iksh$gSVh iksh Bkb ;pzXs jK ns/ w/o/ gfotko d/ fBwB nB[;ko w?Apo jB.

bVh Bkw T[wo foPsk ezw$g?;k fJBew N?e; ftGkr

Bzpo tZb'A ikoh g?B Bzpo

2H fJj fe w/oh s/ gfotko d/ fgSb/ ftZsh ;kb (1 ngq?b s'A______ 31 wkou________) d"okB tZy^tZy ;'fwnK s'A ;bkBk
nkwdB fBwB nB[;ko ;h.

1 ;oekoh$r?o ;oekoh B"eoh dh fvN/b______________ ns/

T[;dh sBykj s'A e[Zb nkwdB
2 fe;/ th soQK dh g?BPB nkfd s'A eZ[b nkwdB
3 p?eK ftZu fce;v fvgkiN;$;/ftzr p?Ae ykfsnK s'A ftnki dh
e[Zb nkwdB
4 r?o^p?fezr ftZsh ezgBhnK ftZu fvgkfiN s'A eZ[b nkwdB
5 y/shpkVh$pkrpkBh tkbh e[Zb IwhB_______ J/eV______
eBkb s'A P[ZX nkwB
6 ewoPhnb gqkgoNh fit/A fe d[ekB, P'n o{w nkfd s'A feokJ/
dh nkwdB
7 fojkfJPh gqkgoNh s'A feokJ/ s'A nkwdB

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 8 fe;/ th soQK dh d[ekBdkoh s'A nkwdB
9 fe;/ th soQK d/ j'o ftT[gko s'A j'Jh nkwdB
10 fwT{ub czvi$;Nke wkofeN s'A j'Jh nkwdB
11 fe;/ profession fit/A fe vkeNo, tehb, nkoehN?eN,
ukoNvnekT{N?AN nkfd s'A gfotkoe w?ApoK dh ;kbkBk nkwdB
12 T[go'es ftZu eto Bk j'D dh ;kbkBk nkwdB
T[es ;ko/ ;kXBK s'A e[Zb ;kbkBk nkwdB

3H j[D tkb/ ftZsh ;kb d"okB w/oh s/ w/o/ gfotko dh ;ko/ ;kXBK s'A e[Zb nkwdB fgSb/ ftZsh ;kb dh T[es do nkwdB s'A
_________________o[gJ/ xZN$tZX j'D dh ;zGktBk j? s/ fJ; xkN/$tkX/ d/ ekoB fBwB nB;ko
jBL_____________________________________________________________________________________________
___________________________________________________________________

fwsh L

;EkBL

T[go'es ;{uBk fpbe[b w[ezwb ns/ ;jh j? ns/ T[es gkoNh e[boI ;pzXh e'Jh th rZb S[gk e/ BjhA oZyh. T[go'es ;{uBk rbs
gkJ/ ikD s/ fBwB j;skyo fe;/ th soQK dh pDdh c"idkoh ekotkJh dk Gkrh j't/rk.

fwsh L

;EkBL (fpnkB eosk)

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 Feed Back Form/ ਫੀਡਬੈਕ ਫਾਰਮ

1. Is there any unnecessary information being asked in the Form?/ ਕੀ

□ Yes / ਹ
eh ਫਾਰਮ ਿਵੱ ਚ ਕੋਈ ਵੀ ਬੇਲੋੜੀ ਜਾਣਕਾਰੀ ਮੰ ਗੀ ਗਈ ਹੈ <
□ No / ਨਹ

If Yes, Please specify the detail/ ਜੇਕਰ ਹ , sK ਵੇਰਵਾ fdT[

2. Is any vague information being asked in the form?/ ਕੀ ਫਾਰਮ ਿਵੱ ਚ eh

□ Yes / ਹ
eh ਕੋਈ ਵੀ ਅਸਪ ਟ ਜਾਣਕਾਰੀ ਮੰ ਗੀ ਗਈ ਹੈ <
□ No / ਨਹ

If Yes, Please specify the details/ ਜੇਕਰ ਹ , sK ਵੇਰਵਾ fdT[

3. Is the space provided in the form sufficient for filling up the

required information?/ ਕੀ ਫਾਰਮ ਿਵਚ ਮੁਹੱਈਆ EK b'VhAdh ਜਾਣਕਾਰੀ ਭਰਨ ਲਈ □ Yes / ਹ
ਕਾਫ਼ੀ ਹੈ □ No / ਨਹ

If No, Please specify the details/ ਜੇਕਰ ਨ , sK ਵੇਰਵਾ fdT[

4. Any other suggestion you may like to make, Please specify / ਕੋਈ ਹੋਰ ਸੁਝਾਅ ਦੇਣਾ ਚਾਹੁੰ ਦੇ ਹੋ ਤਾ ਵੇਰਵਾ fdT[

Last Rev: Aug 2017 Page 9 of 9