Applicalion Form

For
Economically w6aker seclion lncome cerlillcale
For lhe Financlal year

appranr Name C!^,VYolo 'lovo;' 1'vrh'' Frhe, Name' cti.llo\o su'w lo-c
cr*ir"o' auo
DareofB.th:6x 0t-L05
Aadhaar N!mber (opllonal)l

Sub Case Caregorv ' Vofu

L ocality/Land(alk Nut6nnj
?"\or6\'

DeLr.f. tr'Cn Nlandal pu\ato\ Villase': pric,ko\ Pn@de': 63q 2(o

Postal Address is same a

LocarLly/Landmarr. ft.1o*.," letc'

srare': AbN6o Pt{\&!V
Dislict,: w,G Nrandar': pd\t^\(o\
q!6(1\gqqY
^robileNumbea:
Bal o. ca'd Numbe,: )gU1Sl-06 3
lncome peiails'l

Gross Annual tncome incudes Salary, Agricuture, Business Piolession elc., ior
rhe lnancal year prior lo lhe year ol applcation lApplcan'Hls/HeI
Family ) \.\(\,6N6 (ln Fupeas)

(Applicanl/ His/He//Family')

i) sAcres or aqricuLtura! Land and above: Yes/No

I ) Fesi.lenlia fal ol 1000 sq t and above: Yes/No
iii) Resdenla plol oJ 1oo sq yads and above ln nolLled muncpalities:
Ye91!.s.
Resldeniia o.lol2oO sq yards a.d above i areas olherlhanlhe
no11 ed muncipallles Y@Iq
 benelll
lerm Family to'this plrpose wil ncude the pe6onwhoseeks
Nole :The
His/Her parents and s blrnss below
Uc aoa or r8 vears as also
or ReseNauon,
ow ihe aqe oi 13 vears
Fls/Her spouse and ch ldren be

0
ti) P,xon Carcl/Ep c Card/Aadhaar Card-
ii0 Copv 01 lT Relur.s/Pav Slips
(A'vol other Oocumenls)
iv)

Fr ldonl belono lo sC ST andOBC Casr€

* BepresenG al!lhe fie ds are ma'datory'

c\",.Quvo.vi' Lcr'lrh*'
Slqnalue ol lhe APplicant

: Seyv\i4 do )ob:e'\4 uF
qo\n;r]9'r' jl
.o€,n*{
n
dr

.l)'.rt^t :r1+r
 ,A\
E
$ir"-'do
! ed'6 d:9006 0rr.d6, d.
'653:
' 6!"$4 65e es 4...qs ola t4rr5
gr

e&q / E drm.En -rol2hiioztoe

INFORIMATION
. Aadhaar 16 prld
of iderily, ,Et of.iriaBhrp.
E
! Toetsb&n E6n0ly. honli@16 onlire.

tfitmttmflfft
F i.r.: altn!6r e5r6.rl.l.s6
a -jr6 o'.dg!d' d$.t !l.@ iraJsd
s10 0d6c$r4d 6.16 siM
5) ur6 bo.{ / You. AadhaarNo. ! .r€dh.ar is Elid lhEushod rh3 orntry

2145 8766 1930 . Aadhaarw b. h.rptur h *ailing G@mm.nr

.nd Non4o@med s€ ie
ln tutuB.
d" era"6, -" .14o!D

I aoaoo<.
& 6'".,"Mddtb

214587661930
n" a-'a"6, u .bFD I a E
I I
ti

t
1.,TEN
I
! RUPEES
I

s 10
H
I
INDIA
t I
. ;_:, - J rTirT ANDHRAPRAD ESH t]sAB 2 7 780
El) ps*-- lou..zr
I i i rifr-j'"p @-
o
cr'"r$'osc" 's16 '
u ,rprnrvt
aPr{,1 A SLIRYA RAITIACNANDRARAo Sl0 NAGESWARARAo Fro cN .ArA pAVnNtursrh,lij
d RESdCiI AddreSS D,NO ]1]23 NAGARAJU PETA, 3* STREET PALA(OLi:PAIA'(OIJ'JI]
'I
G0d6!aiDstclSlaleofAndhmPradeshanddohelebvsolemnvaffimedandslaleonoalhas
t
rra beon! 1o ECONOTTCALLY WEAKER sEcTloNS (E.WS)CASTE (0C)
arFanenlG O lLls No23l.MemoNo REVoILANAOM SC172I?019'SER l , Daled
2 a iro ngasaDayWageEamer. l,lyrie sahousewile h ave no movab e or lm movable
.""i,
pro penies n
. ,eor ,! r,..- o.ouMot (oree,."p -, . or" v, ho."...edeo.1d'9
ooi ie 'D..q.q1.."'O e dd O% 50 vr Do.q'e. o) d p H.\}Lr Pr.a1l -l,SHll ,
N'-PMEOltrTt - i' el cak! r'Dd.ue'E''_
r-""1oo". t ,, 'o oFF ','ooOO M]"'.,oo"'oror'ooo'*\.cnlo'?oo^'ns
a*els':'
5 a es&asdcutu6 land and aboE
'. Residenlia lla1of1000sq 1l andabove
. Residentia p ot ol I00 sq yads aird abole n ioil ed mun dpa 1es.
. Res denlial plol sq yarns and abole n aeas other lhan lhe mliled Munlcpa
01 2OO
'r rhelacs;td ii all carlrcates prcnuced by melrueto he besl or mv kio{bnge beiel lanvdsepa0'v
rr!.s f E regad ng the conleits menl oned above l an heLd responsib e ior the punishhenl g ven bv he

:r::i:! I23 DEPoNENT

MEiiI" T,IISUI,!'trNTI
ADVOCATEA'IIARY NCiARY ATTESTET)
Vaid Endt. Uo: f;i l'17/2019 Ao.otnt.d bY Govr ol A'P
G O.IMs. No-4?l I
!r'? 2012 P;Li$oL.tl 16r\,!.60lAP lRb .Y i. r'L
PAIAKOLiU 5l'i :r0 A P
. Cerl i01:13 60078
 aO behEbr Form of Transfer Certificate
' ORIGINAL
€ar .o$ ADlrrlssloN No. 11bb
,2019 No. 3863S
TRANSFER CERTIFICATE NO,
(tr) >.ro l)dr (to$. d9 / . Hi6H SCHOOL lt^4,
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non
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PAIANTLAKSHNI
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doc dr tuoolsi 1b SAPYA RANACIIAN
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