Reference No. ‘Application Date Application for Nan-Creamy Layer New (J Renewal {_] Applicant Details | Asdhaar Number ull Name * Gender * Male tl Female Cl Other U 1 Date of Birth * DD wy | Occupation of Applicant* Residence Address * | thease ors te fotoane | sei Buide te /2ulding Rome Scien Complex | name of pos office Villaze District | Fin code. | Permanent Address * (Fit ateren: rom akeve) = aue/tat No, Bulg Mo. /2ulding ame Sciy/Compioe fond ame Nae of Post OFfce | Pin Code Mobile No. * Email | Occupation * Previous NCL certilicate’s details (if applicable} * Certificate Number Place of sue : Yad il Gate DD it Beneficiary Details | Full Name * | Spouse Name *Father's Name * Mother's Name * Address where family Millage l z originally resides™ District Applicant's Relation to Beneficiary * Religion * Caste" | Caste ‘Sub caste Occupation and Income Details of Applicant's Family ® {Please filahe sections as appicablep [Income from Salary/Pension Type of Occupation Father Mother | Spouse Central Government U1 | Ca C7 ‘State Government ti tt a Private Sector tl ti i su C1 ti i tt ti i Armed farces ‘Others [spect) Occupation Details | Father Mother Spouse Name of Organization Designation/Rark Department Salary Range Total Annual income Date of joining (dd/immivwy) | IfPensioner, date of | retirement (dd/mmniyyyy) Income from Business Type of Business. Total Annual income Income from Immovable praperty Ouiner of property Father {J Mother [| Minor] Location ‘Area (vards Sq. Metres /ncres/ Heesares) Type of agricultural land Irrigated ti Dry crop 1-2 Area of irigated land (verds/ | Sq. Metras/Acres/Hactares) | a) Percentage of irrigated land as per constitutional ceiling undar the state land ceiling act formula ‘bj lf you own both irrigated‘and dry land, percentage of irigated land as per constitutional ceiling under | the state land ceiling act formula “AS per a) totalirrigated land 25 a percentage as calculated by ‘the land celling act formula | Cultivation details Type of cultivation Crop to) Fruits 1 Location Cultivated Area (verds Sq Metras,/ neres/ Weetares Details of fand/bullding in urban area Location of property Details of property [Gurrent use of property Total Annual Family income from all sources excluding in words> salary and agricultural income ‘Are you an income tax payee attach assessment if yes} ves tI No tl Have you paid wealth tax [Attach details) ves 01 No ta Fields marked with ® are mandatory) Self-Declaration son/daughter of aged eccupation hereby declare that the information provided above is true and correct to the best of my knawledge, information and belief. | fully understand the consequence of giving false information. If the information as given above is found to be false, | shall be lisble to prosecuo n and punishment under seco n 199 and 200 of IPC 1960 and/or any other law ‘applicable thereto. Place Applicant Signature = Date: Applicant Name