(Format I)

INCOME CERTIFICATE/INCOME DECLARATION

I, (Name of ECHS Beneficiary)

(son/daughter/father/mother/brother/sister) of Army No .
Rank Name resident of village .
Ward No GVS District (Nepal), do hereby solemnly
affirm and declare as under:-

Source of the annual income- for the year:-

(a) Income from Immovable Property -Rs (IC)
(b) Income from Movable Property -Rs (IC)
(c) Income from Employment (Pvt/Govt) -Rs
(IC)
(d) Income from Pension -Rs (IC)
(e) Income from self-employment/business -Rs (IC)
(f) Income from other sources -Rs
(IC)
Total Annual Income -Rs (IC)

AVERAGE INCOME PER MONTHS (ANNUAL INCOME ÷ 12) :- -Rs (IC)

,
(Signature and Thumb Impression of Application)

ATTESTATION (BY VILLAGE DEVELOPMENT COMMITTEE)

Place: (Office Seal)

COUNTERSIGNED BY STATE REVENUE DEPARTMENT/CDO

Place: (Office Seal)