Application Form

For Certificate
Economically Weaker Section Income
For the Financial year
Applicant Details:
Aplicant Name': kalumuvi Haatha Father Name': kot Nobd
Gender: Femalo Date of Birth: Mooh
25lo7/a007
Aadhaar Number (optional):
Gaste Category': Sub Gaste Category*:

Present Address:
gC-Baia
Door No*: 1|-19lA Locality/Landmark: kotunipoll?
State": A-P
Districr6iSatytandal: tmacbgvlage": lhumaa Pincode': 5 l555(
Postal Address is same as Permanent Address:
Door No*: 1|-191
A.?
Locality/Landmark: kattnipal
State*:

DstriarSiSasttyMarda roasp/ Vilage: Thumal Pincode*: 5)6556

Mobile Number*: 553774765 Mail Id:

Ration Card Number:

Income Details*:
Gross Annual Income includes Salary, Agriculture, Business, Profession etc., for
the
the financial year prior to year of application
Family): B0,009 n Rupees) (Applicant/His/Her
AssetsInformation (Applicant/ His/Hander/Family'):
Land
5 Acres of agricultural above : Yes/Nó
Residential flat of 1000 sq. ft.
and above:
Residenfial plot of 100 sq. yards and aboveYes/No
i)
i) in notifiedImunicipalities:
m
Yes/Nd
yard_
Residential plot of 200 sq. and
iv) notified municipalities: Yes/No above in areas other than the
 purp0se will
Note: Theterm
"Family" forthis
parents and
siblings include the person who seeks benefit
Reservation, His/Her below the age of 18 years as also
of belowthe age of 18
His/Her spouse
and children
yearS.
Documentsto be uploaded:
Application Form"
) Card/Aadhaar Card
i) Ration Card/Epic
(Any of other
Copy of IT Returns/Pay Slips
iv) Affidavit
Documents)
Note:

bereby declare that the above meoied information is furnished on

my knowledge. If information & declaration is found
best of
prosecution. false, I am liable for
MI don't belong toSC, ST and OBC Caste.

Represents all the fields are mandatory.

Date:
Signature of the Applicant