To,

The Mandal Revenue Officer,

_________________ Mandal,
Hyderabad, A.P.

Affix 2 Rupees
Court Fee Stamp

Sub:- Application for issue of Income Certificate-Requested Regarding.

Respected Sir,
I,_________________________________________________________________________
S/o,D/o,W/o.______________________________________________________________________
R/o. House No.____________________________________________________________________
I beg to state the following few line for your kind consideration and favorable orders. Herewith
enclosing the Ration Card Copies and Affidavit two different State Govt. Gazetted Officers, i.e.
INCOME CERTIFICATE of myself.
I am residing in the above address which is in the Jurisdiction of Khairatabad Mandal. On the
strength of certified copies submitted to you for verification. I may kindly be issued Income
Certificate, on receipt of certificates from Mandal Officer.
I will submit the same in ___________________________________________________________
for the purpose of __________________________________________________________________
I, therefore humbly request you to issue me the Income Certificate.
Thanking you,
Date:

/20

Yours faithfully,
(

Place: Hyderabad, A.P

Certificates enclosed (Attested by the Gazetted Officer): ( )
1)
2)
3)
4)
5)
6)

Two different State Govt. Gazetted Officers Certificate.

Affidavit with Notary on Rs. 10/- Bond Paper.
T.C or Bonafides Xerox with Attested by the State Gazetted Officer.
Ration Card with Attested by the State Gazetted Officer.
Photo Identity Card Issued by the Election Commission or Electorate rolls from Municipality.
Salary certificate issued by the Employer.

DECLARATION
I declare that the information furnished by me in this application is true and correct. If it is found to
be untrue and incorrect. I will be liable for prosecution for furnishing false information under Section 199 and
200 of I.P.C.

SIGNAURE OF THE APPLICANT

(
)

Income Certificate
This is to certify that Sri/Smt. /Kum.____________________________________________________
S/o,D/o,W/o._____________________________________________________________________________
R/o. H No._______________________________________________________________________________
is residing in the above Address and working Privately/ Private Servant/ Own

Petty Business as

a_______________________________________________________________________________________
His/Her monthly Income is Rs.___________________ and annual Income is Rs._______________________
With all sources.
I know him/her well with the best of my knowledge and hence this income certificate is issued under
G.O. Ms. No. 554 dt:4-8-1988 Revenue (A) Dept., and G.O. Ms. No. 178 dated: 6-8-1988, Social Welfare
(J2) Dept. G.o. Ms. No. 289 dated 28-11-1989, Social Welfare Department.

Signature of the State Gazetted Officer

Date:
Designation:
Official Seal:
NAME:

Income Certificate
This is to certify that Sri/Smt. /Kum.____________________________________________________
S/o,D/o,W/o._____________________________________________________________________________
R/o. H No._______________________________________________________________________________
is residing in the above Address and working Privately/ Private Servant/ Own

Petty Business as

a_______________________________________________________________________________________
His/Her monthly Income is Rs.___________________ and annual Income is Rs._______________________
With all sources.
I know him/her well with the best of my knowledge and hence this income certificate is issued under
G.O. Ms. No. 554 dt:4-8-1988 Revenue (A) Dept., and G.O. Ms. No. 178 dated: 6-8-1988, Social Welfare
(J2) Dept. G.o. Ms. No. 289 dated 28-11-1989, Social Welfare Department.

Signature of the State Gazetted Officer

Date:
Designation:
Official Seal:
NAME: